Accident Report

This form must be completed by an employer when an employee suffers death, permanent incapacity or incapacity arising out of, or in the course of the employment.

Please complete all fields. If a question is not applicable, type "N/A" in the field.

This form must be provided to Gallagher Bassett within 7 days after the death, permanent incapacity or incapacity became known to the employer.

Full name of employer

Note - if the employer is a company or other body, please give the full legal name of the body.

Postal address of employer

Employer's business telephone number

Employer's email address

Injured employee's First name

Middle name

Surname

Preferred name

Gender

Date of Birth

Injured employee's postal address

Suburb

State

Postcode

Injured employee's phone number

Injured employee's email

Injured employee's occupation

Type of Claim

Was the employee engaged in this occupation when the relevant accident/incident occurred?

No Yes

State exactly what the employee was doing at the time of the accident/incident, and whether the accident/incident occurred during a meal break or other work break

Date first employed

State rate of wages etc paid at the time of the accident/incident:

Basis of payment (weekly etc.)

Payment amount ($)

Normal working time per week:

Number of days per week

Number of hours per week

Is board or lodging provided by the employer?

No Yes

State value per week ($)

State total earnings of the employee in the 12 months prior to the date of the accident or illness.

Note - include all payments and non-cash benefits (eg commissions, board, lodging, etc).

Total sum ($)

Number of weeks

Average earnings per week ($)

Date of accident/incident

Day of week

Time of day

Did employee cease work immediately?

No Yes

When did the employee cease work?

Number of hours lost on last day at work

State full address of premises where accident/incident occurred

Suburb

State

Postcode

Did the injury/incident happen during a motor vehicle journey?

No Yes

Please give full details

Did the employee notify the accident/incident before leaving the place of employment on the day of the accident/incident?

No Yes

When was the accident/incident first reported?

Was the employee injured (etc) while doing something which was not part of the employment, or at a place where the employee was not required by the employment to be?

No Yes

Please give details

Are you satisfied that the accident/incident happened in the course of employment and in the manner stated by the employee?

No Yes

State the reasons for your conclusion

State the apparent cause of the accident/incident

Note - Give full and particular details.

Give the names of all witnesses to the accident/incident

State apparent nature and extent of injury or illness

Did the employee receive any ambulance, medical, surgical or hospital treatment?

No Yes

Please give brief details of the treatment

Is there any additional information about this claim you wish to raise?

WORKERS COMPENSATION CLAIM / ACCIDENT FORM

SUPPORTING DOCUMENTS

DECLARATION

WORKERS COMPENSATION CLAIM / ACCIDENT FORM

SUPPORTING DOCUMENTS

DECLARATION

Required documents