Form · Personal Injury & Compensation

WorkSafe claim for compensation following a work-related death: completion guide

Link to the WorkSafe form used after the death of a worker from a work-related injury or illness, including dependency, grief and loss, and funeral expenses.

Kind: Form. A form to complete, or a guide to completing an official one.
Where it applies: Victoria
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 worksafe.vic.gov.au and the 3 authorities it cites, for Victoria.
Version: 1
Source: Link to the official form. Licence: © State of Victoria. Link only: download the current form from the official page each time; do not copy or adapt it.

Where this comes from

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

When to use it

Use when a dependant or another person is claiming compensation after a worker has died from a work-related injury or illness. The person completes the current PDF in Adobe Reader. For a living worker, use the worker's injury claim form.

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 death certificate, funeral invoice and relationship documents the lawyer has collected; the family completes the current PDF and the lawyer checks every statement.

AI may

Index the death certificate, funeral invoice and documents showing relationship or dependency
List which of the manual's heads the instructions mention: dependency lump sum or pension, grief and loss, burial or cremation, and medical and like expenses

AI must not

Must not describe how the worker died or decide who is a dependant
Must not write answers into the PDF
Must not require a medical authority. The claims manual says a valid claim needs a signed medical authority except for a claim relating to the death of a worker

The lawyer checks

The PDF is downloaded and completed in Adobe Reader. The page says a browser may not save it
The claims manual says a dependant or another person may claim a dependency lump sum or pension, a grief and loss lump sum, and burial or cremation, including repatriation, and medical and like expenses
The manual says the form is not mandatory for a non-dependent family member seeking reimbursement of expenses
The manual ties the form to section 20. A signed medical authority is not required on a death claim
Health information stays in a firm-controlled tool. Check ASCR r 9, APP 11, and whether any disclosure would be a notifiable breach 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 of Victoria. Link only: download the current form from the official page each time; do not copy or adapt it..

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The summary, the law it rests on and the AI-use guidance above stay public. Privacy.

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