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Online Claim Form - Public Or Private Place

Let Us Help You

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.

Name

Surname

Given Name(s)

Address

Home Address

Postal Address

Contact Methods

Contact Number

Email Address

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, otherwise please call (131 444)

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

Please confirm that you have read the Privacy Policy

Please tick

Yes

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

Please tick

Yes

Let Us Help You

Online Claim Form - Public Or Private Place

Let Us Help You

Online Claim Form - Public Or Private Place

Lodge Your Claim Online

Name

Address

Contact Methods

Date Of Birth

Interpreter

Date and Time

Incident Report

Other Parties Involved

Location of the Accident

Description of the Accident

Did Police Attend the Accident

Did you attend Hospital

Your Treating Doctor

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

What are your continuing disabilities

What is your occupation

What is your weekly net income?

How long have you been off work since the incident

Have you returned to work

Have you had any prior injuries or claims

Please confirm that you have read the Privacy Policy

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

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