claims external - Hotel Employers Mutual

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

Has the worker received treatment for this injury other than simple first aid?*YesNo

Has the worker missed any time from work due to the injury?*YesNo

Employer's Details

Business name (legal name)*

Contact name*

Contact number*

Contact email*

Policy number

Cost centre

Business address*

Worker's Details

First name*

Last name*

Gender

Address*

Contact number*

Email address* Email unknown

Date of birth

Does the worker require a translator?

Language:

What is their occupation?*

What is their employment status*

Do you have an available copy of the worker's pay summary for the 52 weeks prior to the injury?

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:
a) Hours per week
b) Hourly award rate

Injury Details

Injury date*

Injury time*

On what date was the injury reported to the employer?*

Tell us briefly how the injury occurred*

What part of the body was injured? i.e. right foot, left shoulder*

What type of injury is it?* i.e. burn, sprain, cut*

Where was the worker when the injury happened?*

Treatment Details

What treatment has the worker received for this injury?*

Details*
Name of Doctor or Hospital*
Phone
Address

Has the worker been issued with a medical certificate?*

Are you able to upload a copy of the certificate?

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

If you know the details of the certificate please provide them here
a. Capacity as shown on the certificate:
b. Medical Certificate date to:

Notifier's Details

If the same as employer contact details please click here

Notifier's name*

Contact number*

Address*

What email address would you like the confirmation sent to*

What is your relationship to the worker?*

Is there anything else you would like to tell us regarding the incident?

For further information on our privacy practises please click here and select the Privacy Statement applicable to you. By providing this information I agree to the Hospitality Industry Insurance Limited Privacy Statement.

Please verify if you're a human:

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.