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Online Claim Form - Public or Private Place

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Lodge your Claim Online

We have made it easier for clients to give all information accurately so that we can open up your compensation claim efficiently. This form is for any incidents on at a public or private premise.

By submitting your online claim, you agree to the Privacy Policy which can be found here.

Personal Details

Personal Details

Accident Details 1

Accident Details 1

Accident Details 2

Accident Details 2

Injuries

Injuries

Declaration

Declaration

  • Personal Details
  • Accident Details 1
  • Accident Details 2
  • Injuries
  • Declaration

Name

Surname

Given Name(s)

Address

Home Address

Postal Address

Contact Methods

Contact Number

Email Address

Date Of Birth

Date of Birth

Interpreter

Language

Date and Time

Date

Time

Incident Report

Name of Person to whom incident reported

Address

Phone Number

Other Parties Involved

Please provide as much information as you can

Location of the Accident

Location

Description of the Accident

Describe how the accident happened

Did Police Attend the Accident

Please Select

If so, what is the Event Number

Did you attend Hospital

Please Select

If so, which Hospital

Your Treating Doctor

Doctor’s Name

Address of Doctor’s Practice

What injuries have you sustained as a result of the incident?

Injuries sustained

What are your continuing disabilities

Disabilities

What is your occupation

Occupation

What is your weekly net income?

Income

How long have you been off work since the incident

Time

Have you returned to work

Please select

Have you had any prior injuries or claims

Please select

If so, please provide details

Please confirm you have read the Privacy Policy

Please select

Please confirm you have read the Privacy Policy

Please tick

Please confirm that all information you have given in the claim form must be true and correct in every respect

Please tick