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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

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

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