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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
Some required Fields are empty
Please check the highlighted fields.
Please check the highlighted fields.