COVID-19 Related Claim Notification ‐ Workers Compensation Portal

COVID-19 Related Claim Notification

If the claim is not for COVID-19 please submit via 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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Employer's Details

Employer Name

Employer Name is correct

Cost Centre / Venue

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

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

What type of injury is it?

Description of injury

Do you have evidence of a positive result i.e. copy of SMS or a letter from NSW health or a Certificate of capacity?

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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

When did they commence employment?

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

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