Employer report form

If a worker is injured in your workplace and wants to lodge a compensation claim for that injury, you are required to complete an Employer Report Form.

Make a claim over the phone

Phone WorkCover Early Claim on 13 18 55 to report the injury and start the claims process.

Submit the form

Complete the PDF employer report form. You must print your application before exiting the document as your information will not be saved. 

Employer report form [564KB]

Printing of the form will produce two (2) copies - keep one copy for your company records, and send the second signed copy through to WorkCover either by post to: 100 Waymouth Street, Adelaide 5000 or facsimile on (08) 8233 2211. Please be aware that this form cannot be emailed through to WorkCover.

Use the Print Form button on the Acrobat document message bar.

Do not use the browser or Acrobat Reader toolbar Print buttons, as they will not produce 3 copies of the form.

This form is not required to be printed in colour. You can authorise another person to complete this online form on your behalf.