Initial notification of injury form where policy details are not known

To notify us on an injury, please answer the following questions. Questions marked with an asterisk* are mandatory. Once you submit this form, a case manager will be in contact within 48 hours.

    Claim Details

    YesNo

    YesNo

    Employer's Details

    Worker's Details

    Email unknown

    Language:

    Please upload documents here.
    File types accepted include: DOC, DOCX, PDF, JPG, PNG. Maximum file size allowed is 20MB

    If you know the worker's wage details please provide them here:

    Injury Details

    Treatment Details






    Notifier's Details

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    Please note that if the incident involves a death, ‘serious’ injury or ‘dangerous occurrence’, you must also notify SafeWork NSW immediately on 13 10 50 – please refer to the SafeWork Australia’s notifying fact sheet for further information.