Form · Personal Injury & Compensation

Permanent impairment claim form (SIRA): lump sum workers compensation

Link to SIRA's permanent impairment claim form, with the form's own threshold words set beside the 11% and 15% figures on SIRA's current permanent impairment page.

Kind: Form. A form to complete, or a guide to completing an official one.
Where it applies: New South Wales
AI use: Yellow You and the tool draft together, with you directing. You check every statement you rely on.
Law stated as at: 23 October 2026
Status: Maintained. Checked on 23 October 2026 against the official form at sira.nsw.gov.au and the 3 authorities it cites, for New South Wales.
Version: 1
Source: Link to the official form. Licence: © State Insurance Regulatory Authority. Link only: download the current form from SIRA each time. Do not copy or adapt it.

Where this comes from

The official form is published by sira.nsw.gov.au; this page is a completion guide. Last checked on 2026-10-23.

When to use it

Use when a worker in NSW claims lump sum compensation for permanent impairment after maximum medical improvement. Check the current Act and SIRA's permanent impairment page before the form is sent. The 2019 PDF and that page do not use the same percentage.

Used for these tasks

Each task page says how far AI may help with the task and what the lawyer must review.

How AI may be used

The tool may index the assessor's report and list the attachments the form asks for, and it writes nothing in the declaration and does not state the percentage threshold as settled.

AI may

Index the permanent impairment report by assessor, body system, date and the percentage stated in that report
List whether a worker's injury claim form, an audiogram, or a pre-2002 report is on the file
Record the dates on the form PDF and on the SIRA permanent impairment page so the two threshold wordings can be compared

AI must not

Must not write section 8, the worker's declaration, or the worker's account of the injury
Must not treat the PDF's words 'more than 10%' as the threshold in force
Must not decide maximum medical improvement, whole person impairment, or whether a further claim is available
Must not sign or send the claim

The lawyer checks

Check the current Act. The PDF (catalogue SIRA08797, copyright 0119) says the claim can only be made where maximum medical improvement has been reached and the degree of permanent impairment is more than 10%
The SIRA page opened on 23 October 2026 says a lump sum claim made on or after 19 June 2012 requires 11% or more for a physical injury, or 15% or more for a primary psychological injury
That page says permanent impairment compensation is not available for secondary psychological injuries, and that there is one claim per injury, with a possible further claim if a claim was made before 19 June 2012 and the condition deteriorated
The report is from a SIRA-listed assessor trained in the body system where the injury is on or after 1 January 2002, or supports the loss claimed where the injury is before that date
Hearing loss: the audiogram is attached and section 6 of the form is used
Insurer times on the SIRA page: one month to accept and offer or to dispute, and the two-week and two-month extensions if more information or an examination is required
Health, wage and other personal information stays in a firm-controlled tool. Check confidentiality under ASCR r 9 and APP 11, and whether any breach is notifiable under the Privacy Act 1988 (Cth).

Method: how the Green, Yellow and Red levels are decided. This is guidance for planning, not legal advice.

Authorities

Official form

Open the official form. Always use the current version from the issuer. Licence: © State Insurance Regulatory Authority. Link only: download the current form from SIRA each time. Do not copy or adapt it..

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