We will then decide the claim based on workers’ compensation legislation and advise you of the outcome Workers Claim For Compensation Form TAS (PDF, 202 kb) Direct Credit Application Form (PDF, 90 kb) WorkCover Tas – Summary of changes to laws Workers IS-139 (PDF, 170 kb) Information for Workers Rights & Responsibilities (PDF, 78 kb) Internal Dispute Resolution Process (PDF, 162 kb) Medical and/or Other Expenses Form (PDF, 76 kb) Conciliation (PDF, 1 mb) Gym and Swimming Memberships (PDF, 342 kb) Household Help and Gardening Assistance (PDF, 244 kb) Medical and Like Expenses (PDF, 394 kb) Service Charter (PDF, 870 kb) Worker Reimbursement Request Form* (PDF, 1 mb) Recovery at Work (PDF, 296 kb) Direct Deposit Form (PDF, 45 kb) Workers Injury Claim Form (PDF, 232 kb) Request for Conciliation Form. WorkCover Policy Cancellation Form VIC (PDF, 213 kb) Employer Transfer Policy VIC (PDF, 93 kb) Adding a Workplace to a Worksafe Policy VIC (PDF, 310 kb) Workers Compensation New Policy Application Form (PDF, 293 kb) Make a claim as soon as possible. Notice of right to make workers compensation claim (PDF, 168.6 KB) Workers compensation claim form (PDF, 194.9 KB) Guides. If the writeable PDF version of the claim form is … Please read the form carefully and ensure that: All details provided are correct, You retain a copy of the form for your own records; and. Page 4 of 8. What you will need: A scanned copy of a signed Worker's Injury Claim form. Please return your completed Travel Reimbursement Form to: Attention: (Your Case Manager’s Name) Xchanging GPO Box 751 MELBOURNE VIC 3001 If you have any queries regarding your travel expenses, please contact your Case Manager on 03 9947 3000. The maximum size for each file is 14MB. Claims Manual. 2.2.1 Worker completes claim form Where to get forms. After a workplace death: A support guide for families, friends and work colleagues (PDF, 378.6 KB) Guide to workers rehabilitation and compensation: For claims on or after 1 July 2010 (PDF, 373.0 KB) Claim form Workers’ Compensation and Rehabilitation Act 2003 Before making a claim, workers need to: • notify employers about injuries • see a doctor and get a workers’ compensation medical certificate. Workers can access approved forms from: WorkSafe website by accessing the editable PDF version; their employer; the local post office; any Agent; calling WorkSafe on 1800 136 089. This Manual has been developed by WorkSafe Victoria for use by its staff and authorised Agents who manage WorkCover claims to assist with decision making in line with the legislation. Please create a separate lodgement for each claim. FOR HELP COMPLETING THIS FORM OR FOR MORE INFORMATION CONTACT: • Your employer or the nominated Return to Work Coordinator at your workplace • Your employer’s WorkSafe Victoria (WorkSafe) Agent - to find out who the Agent is check the If you are injured. Injury Claim Form when signed) If the claim includes weekly payments, send this completed form, the completed Worker’s Injury Claim Form, and any WorkSafe Certificate of Capacity (medical certificates) to your Agent as soon as possible, but no later than 10 days after receiving them from your worker - or you may be financially penalised If your injury was the result of driving or using a motor vehicle or the use of public transport, please provide the following details: The police station the accident was reported to Registration number(s) of involved vehicles State Other injury claim form. Note: The first medical certificate for a work-related injury/condition WorkSafe claim must be issued by a medical practitioner. Adobe Acrobat pdf, gif, tiff, jpeg, txt, doc, docx, xls, xlsx are accepted file types. Policy Forms. poster or call the WorkSafe A scanned copy of any claim-related documentation. INJURY CLAIM FORM FOR502/11 /12.16. • The certifier will use this Certificate of Capacity to communicate with your employer and your case manager about your work capacity (refer to the TAC or WorkSafe Victoria (WorkSafe) website for who can certify). Completed forms must be sent to the ACCS. If you require a hardcopy Request for Conciliation Form, please contact the ACCS.
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