Workers Comp claim form | Guild Insurance

Workers Compensation Claims

To notify us of an event relating to a claim please fill this form with the most accurate details of the event possible. A confirmation of this submission and a copy of your responses will be emailed to the Reporter's email address upon completion and submission of the form.
If you have any further inquiries please call us on 1800 810 213

What is your Policy number?*

Are you a:*

Employer
Employer representative
Worker
Worker representative
Medical / Health Practitioner

Reporter's name*

Reporter's telephone number*

Reporter's Email address*

Type of Notification*

Notification Only (no loss of wages or medical expenses)
Medical Only (no loss of wages but medical expenses)
Medical and Time Loss (lost wages and medical expenses)

Employer name

Contact person at workplace

Employer's telephone number*

Employer's email address

Is the Employer registered for GST?*

Yes
No
Unknown

Please provide your ABN?

Has an input tax credit for the GST included in the insurance policy premium been claimed?*

Yes
No
Unknown

Was the amount of GST claimed less than 100% of the GST included in the premium?

Yes
No
Unknown

Please specify the percentage of GST claimed (1%-99%)

Worker's Name*

Workers gender

Workers address

Worker's telephone number

Worker's email address

Is an interpreter required?*

Yes
No

Provide the primary language required*

Employment status

Full-time
Part-time
Temporary
Casual

Date employment started

Employee occupation*

On what date did the incident/injury occur?*

Time of incident/injury?*

At what address did the incident/injury occur?*

Please describe what happened*

Injury details*

Date injury was reported to employer*

Date Worker first sought medical attention*

Who is the nominated treating medical practitioner

Pre-injury average weekly earnings

Pre-injury average weekly hours worked

Were there any Witnesses?

Yes
No

Please provide witness details