Part 1
To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1.
Notify your employer of your injury or disease verbally or in writing, as soon as practicable.
Fully complete Part 1, numbers 1 to 9, of the following claim form. The more information you provide on the form, the quicker the claim can be progressed. If there is not enough space on the form to include the relevant information, please use the space provided on the back page of this document. Claims should be made within 6 months, however, in some circumstances a claim can be made later. If you are unable to fill in this form and someone else does it for you, they must provide their details on the form at the end of Part 1 number 9.
Sign and date the ‘Workers authority to release medical and relevant personal information and declaration’ located at number 9 on the claim form. The claim will not be accepted without your signature. You can sign using the following: by pen (hand-written); e-signature or electronic signature - an image of your signature scanned and inserted in the signature section of the form; digital signature - an encrypted digital code appended to the form to verify that it was created by a known source and has not been altered. You cannot type your name in the signature block, even if this is converted to a stylish script.
You must obtain a NT Workers Compensation ‘Statement of Fitness for Work – First Certificate’ from your treating doctor and submit it with your claim form if you are claiming compensation for loss of income.
Keep a copy of your Workers’ Compensation Claim Form and any documents you have attached for your own future reference.
If you are claiming compensation for medical expenses only, you need to provide the relevant accounts or receipts with your claim form. You do not need to attach a ‘Statement of Fitness for Work’.
Deliver your claim form by hand or mail or email to your employer as soon as possible. If you are mailing the claim form then it is advisable to send it registered mail. If you are emailing the claim form then it is advisable to request a delivery receipt.
What next
Once you have completed Part 1 of this form and given it to your employer, your employer must complete the employers report Part 2, numbers 10 to 14. Your employer has 3 working days to submit the claim to their insurer. The insurer has 10 working days after the employer received the claim from you, to make a decision and notify you. The possible decisions are:
  • Accept liability for the claim
  • Defer accepting liability for the claim
  • Dispute liability for the claim

The insurer will advise you of your rights and entitlements for the different types of decisions. If this does not happen you can request that they do so, or contact NT WorkSafe for information.

Return to work
The purpose of workers compensation is to provide effective rehabilitation and economic support to injured workers. It allows for prompt and effective management of workplace injuries in a manner that promotes and assists the return to work of injured workers as soon as practicable and the effective rehabilitation of injured workers. You are required to cooperate with reasonable medical, surgical and rehabilitation treatment and you must participate in the return to work process.

The role of NT WorkSafe
The role of NT WorkSafe is to administer and enforce the Return to Work Act. NT WorkSafe provides a claims mediation service and will arrange a medical panel for disputed permanent impairment assessments. Claims are managed by approved insurers and self-insurers. NT WorkSafe has no legislative power to review claims decisions made by insurers. This power rests with the Work Health Court.

Disputes
Should you disagree with any decision made by the insurer regarding your workers compensation claim, please contact the insurer for information on their internal dispute resolution process or contact NT WorkSafe for information on mediation and dispute resolution procedures on 1800 250 713 or visit NT WorkSafe website.

Further information
Further information is available on the NT WorkSafe website, www.worksafe.nt.gov.au or by calling NT WorkSafe toll free number 1800 250 713 (Australia wide).
 
 1.  Worker details
Title:

 
First or given name:
Last or Surname or Family Name:
Other names you have been known by:
e.g. maiden name, previous married or de facto name
Gender:  
Date of birth:
 
Residential Address:
Suburb
State   Postcode
 
 
Postal Address:
Suburb
State   Postcode
 
 
Phone:  
Email:
Country of birth:
Language spoken at home:
Marital Status:
Dependants: Spouse?
Children?  
If yes, how many:  
Date/s of birth:
 
 
 2.  Workers job
Name of employer at time of injury or disease:
Your occupation and job title at the time of injury/disease?
At the time of the injury I was working as a:
Are you:
       
Are you an Apprentice / Trainee:  
       
Do you have any other paid employment?  
If yes, give full name and address of employer:
Full name of employer:
Employer address:
Suburb
State   Postcode
 
 
 
 3.  About the claim
Where did the injury / disease occur? Please tick:
 
Exact location or address the injury / disease occurred:
When did your injury happen or you first become aware of the disease?
 
(GMT+09:30) Darwin
 4.  About the incident
What were you doing at the time - how did the injury happen or what caused the disease. Include any object or substance involved. For example grinder, saw or drill.
 5.  About the injury / disease
Part of body affected:
Type of injury or disease e.g. fracture, burn etc.
If more than one injury which is the most serious?
 6.  Witnesses
Name and contact details of any person who was present at the time of injury:
Person name:
Home number:
Email address:
 
Witness address:
Suburb
State   Postcode
 
 
 7.  Other information
Did you report the injury / disease to your employer?
If no, reason not reported:
 
If yes, date and time injury was reported:
 
 
(GMT+09:30) Darwin
  Name of person you reported it to:
 
  Position in the company:
 
 
Did you stop work because of your injury or disease?
 
   
If yes, date and time you stopped work:
 
 
(GMT+09:30) Darwin
  Time you started that shift:
 
 
If you stopped, have you started back at work now?
 
   
If yes, date started back:
 
 
Did you receive any medical treatment following your injury or disease?
 
   
If yes, name and address of doctor and/or health worker:
 
Title:
Name:
Address
Suburb
State   Postcode
 
Dates you were treated:
 
Were you admitted to hospital?
 
   
If yes, name and address of hospital:
 
Hospital name:
Address
Suburb
State   Postcode
 
 
Are you still receiving treatment?
 
   
If yes, name and address of doctor and/or health worker
Title:
Name:
Address
Suburb
State   Postcode
 
 
What are you claiming for?
 
Have you suffered a similar injury/disease before?
 
   
Name and address of the doctor who treated you:
 
Title of person treating you:
First name: Last name:
Address
Suburb
State   Postcode
 
Type of injury/disease:
When did the injury/disease occur?
 
Have you claimed workers compensation for the same or similar injury?
 
   
If yes, when was the claim made?
 
  Employer name:
 
  Name of insurer (if known):
 
 
 8.  Previous employers
Could the injury/disease you have described in this claim have been contracted in previous employment?
 
   
If yes, name of previous employer:
 
Employer suburb/town:
Period of employment:
Name of insurer (if known):
 
 9. Workers authority to release medical and relevant personal information and declaration
This authorisation and declaration must be signed or your claim will not be considered by the insurer
I authorise and consent to any person who provides me with a medical or hospital service, if requested by my employer or their insurer or the employer or insurer’s appointed service providers, for the disclosure and release of information regarding the service that is relevant to the injury or disease for which I have made a workers compensation claim. This authorisation and consent extends to the collection, disclosure and release of any health and related personal information that is relevant to the injury or disease for which I have made a claim, by my employer or their insurer or the employer or insurer’s appointed service providers, including the disclosure and release of such information to each other, and/or to one or more of the following: the Work Health Authority (NT WorkSafe), a legal practitioner, medical practitioner, investigator, accredited vocational rehabilitation provider, or any other person reasonably consulted by the employer or insurer for making a decision as to payment of the claim for compensation.
I consent to NT WorkSafe using the information collected in connection with my claim to fulfil its obligations under the Return to Work Act or for the purposes of research about workers compensation, workplace injury management and work health and safety. I understand that if this claim results in my receiving weekly compensation payments, I am required to notify the party paying my benefits if I commence employment with some other person, and that failure to do so is an offence. I have read the information provided in this form. I declare that the information supplied in this form, and any attachments to this form, is true and correct to the best of my knowledge. I understand that making a misleading statement or giving a document that contains misleading information is an offence.
Name:
Date of birth: Date of injury:
Type of injury or disease:
Date that claim form forwarded to employer:
 
Signature:
 
 9A. If you are completing this claim for the injured or diseased person, complete:
Name:
Address:
Suburb
State   Postcode
 
 
Once you select Submit Form you will be provided with a link to upload your NT Statement of Fitness to Work
 
 
(GMT+09:30) Darwin