Incident Notifications

INITIAL NOTIFICATION OF INJURY
Workers Compensation Act 1987

This form is to be used when a worker suffers a workplace injury or illness where workers compensation is or may be payable. Notify your Agent within 48 hours. Notify injuries without delay, even if all the information is not known.

All fields are required unless marked as optional.

1. WORKER’S DETAILS

	Policy Number
	Family name
	Given names
	Occupation
	Date of birth
	Gender	Male Female
	Residential address
	Street
	Suburb
	Postcode
	Phone
	Work
	Mobile
	Home

2. EMPLOYER’S DETAILS
	Company name
	Date employer notified of injury
	Number of employees
	Location of business premises
	Street
	Suburb
	Postcode
	Name of workplace contact, if known (eg. name of return to work coordinator)
	Name
	Phone
	Email Address

3. EMPLOYMENT DETAILS
	Employment status (eg full time; part time)
	Normal weekly hours
	Gross weekly earnings
	Notification only? (Nil time lost and/or Nil treatment)	Yes No

4. INJURY DETAILS

Description of incident
(eg. slipped from a ladder while painting the ceiling)

Description of injury
(eg. concussion and broken right arm)

	Date of injury
	Time of injury
	Where did the incident happen?		At work – meal break At work – road traffic incident At work – working normal workplace Away from work during recess period (e.g. coffee break) Commuting to workplace At work – working away from normal workplace
	Has the injured worker returned to work?		Yes No Don't know
	If Yes, state date returned
	If No, estimate date of return

5. TREATMENT PROVIDER DETAILS

	Has treatment commenced?	Yes No
	Completion of the following fields are mandatory only if the response to the above question is 'Yes'
	Provider’s name
	Address
	Street
	Suburb
	Postcode
	Phone
	Type of treatment (e.g. physiotherapy, counselling)
	Any Medical investigations?	Yes No
	Type (eg XRay; MRI; Ultrasound; CT Scan)

6. TREATING DOCTOR'S DETAILS
	Doctor’s name
	Hospital name (if worker hospitalised)
	Phone
	Workers Compensation Medical certificate issued?	Yes No

7. NOTIFIER’S DETAILS
	Name
	Relationship to worker or employer
	Address
	Street (optional)
	Suburb (optional)
	Postcode (optional)
	Phone
	Work (optional)
	Mobile (optional)
	Home (optional)