This form is for injured workers to fill out to lodge a work-related injury claim.
File type and size
PDF, ~385 kB
Document length
8 Pages
Instructions
- As a worker, you need to complete questions 1-6 in Part A of this form using a dark blue or black pen
- Sign the authority to release medical information and worker’s declaration at question 6. The form cannot be accepted without your signature.
- Give both parts of this form (after you have completed Part A) to your employer as soon as possible after being injured
- Please keep a copy for your records
Note
If you have difficulty giving this claim to your employer, or your employer refuses to take receipt of the claim form, you can contact us directly and we will be able to help you out.