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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
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 you have read the Privacy Policy
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.