Claim form

What is this form?

A WorkCover Claim form can be used to notify a workplace injury or seek compensation payments if you have been injured at work with an employer registered in South Australia. Alternatively, this information can be provided by telephone to Employers Mutual or the self-insured employer.

Receiving this information will enable a request for compensation to be considered and will provide sufficient information for the case manager to assist in the return to work process.

If there is insufficient space provided for any of the questions, please attach additional information. A copy of this form should be kept for your records.

Download a copy of the claim form [224KB]

Who can fill out this form?

• An injured worker
• An employer*
• A representative, such as a treating doctor, first aid officer or a worker’s relative or friend

It is important to ensure that the employer is notified (if you are not the employer) and has also been provided with these details if you are notifying Employers Mutual directly (unless the worker is not in employment at the time of injury).

* An employer may complete this form to notify of an injury or begin the claim process, however they may be asked to complete an Employer Report Form if the claim will be ongoing after 13 weeks and additional information is required.

Where does this information go now?

The information in this form can be provided to:

Employers Mutual
By phone: 1300 365 105
By fax: (08) 8127 1200
By post: GPO Box 2575, Adelaide SA 5001
Online at: www.employersmutual.com.au

OR

Self-insured employer
In accordance with the procedures issued by the individual employer.

Hard copy forms are available from WorkCoverSA, Post Offices and Employers Mutual.

Further information on completion of the claim form

A notice of injury only under section 51 of the Workers Rehabilitation and Compensation Act 1986 (the Act) means that you wish to give written notice that an injury has occurred, but do not request any compensation payments at this time. If, at a later date, you wish to claim compensation (weekly payments and/or other expenses) you will need to lodge a claim for provisional payments under Division 7A or section 32A of the Act (provided it is within the first 13 weeks since the injury) or section 52.

A notice of an injury and request for provisional weekly payments means that you seek weekly payments of compensation (under Part 4, Division 7A of the Act) and/or medical and other expenses (under section 32A). Provisional payments under these sections will start within 7 calendar days (in most cases) but weekly payments will be limited to 13 weeks and medical and other expenses will be limited to $5000. If payments are likely to exceed these limits, you are entitled to make a claim for compensation under section 52 of the Act, even if you have already given a notice of injury and sought provisional payments. If a claim for compensation is made under section 52 of the Act, payments will start if and when the claim is accepted. This covers ongoing weekly payments and medical and other expenses. If you wish to make a claim for compensation under section 52, please contact your case manager.