Claim Notification ‐ Workers Compensation Portal

Claim Notification

If the claim is for COVID-19 please submit via Covid Claim Notification
If you have any concerns or issues completing this form please contact Hospitality Industry Insurance on 02 8251 9069

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* indicates a required field

Please select appropriate injury type *

Injury Notification: Use this option if the worker has experienced an injury that requires medical treatment and/or time off from work or normal duties.

Notification of Incident Only: Use this option if an incident occurred but no medical treatment or time off from work and normal duties is required

Employer's Details

Employer Name

Employer Name is correct

Cost Centre

Contact Name

Contact Number

Notifier's Details

If the same as employer contact details, please click here

Notifier Name

Contact Number

What email address would you like confirmation sent to?

What is your relationship to the Worker?

Injury Details

Date of Injury

Time of Injury

On what date was the injury reported to the employer?

What industry is the worker employed in?

Where was the worker when the injury happened?

Location of injury

If applicable

Injury Type *

Acute Injury
Injury resulting from the nature and conditions of employment
Psychological

Description how the injury happened

Description of injury

What type of injury is it?

What part of the body was injured?

What action, exposure of event resulted in the injury?

What object, substance or circumstance caused the injury?

Do you have a certificate of capacity? *

Yes No

Is the worker in hospital?

Hospital Name

Worker Details

First Name

Last Name

Gender

Physical Address

If applicable

Same as Physical address

Postal Address

Mobile

Either mobile or email is required.

Home Phone

Email address

Either mobile or email is required.

Date of Birth

Does the worker require a translator?

Language

What is their occupation?

What is the employment status?

Full time

Part time

Is there anything else you would like to tell us regarding the notification?

Yes No

Please upload any other information in relation to this notification to assist with the management of this claim

Accept file types .pdf, .doc, .docx, .jpg, .jpeg, .png, .bmp, .tif, .tiff, .msg

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