AI Law Framework

Form · Personal Injury & Compensation

WorkSafe Form A, application for common law damages: completion guide

Guide to WorkSafe Form A for an application under section 328 of the Workplace Injury Rehabilitation and Compensation Act 2013 or section 134AB(4) of the Accident Compensation Act 1985.

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 worker is applying to WorkSafe or a self-insurer for common law damages under the Ministerial Directions that commenced on 1 November 2024. The worker signs Form A. The affidavit that accompanies it is sworn and is not written here.

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 build the Part E document index from material already on the file; the lawyer completes Form A and the worker signs the acknowledgment, and the tool writes nothing in the affidavit.

AI may

  • Index medical and treating practitioner reports already held, with author, date and specialty, for the lawyer's Part E table
  • List employers named on the file for the three years before each injury relied on, through to the application date
  • Check the draft index against Part E: Form A, signed Form D, statement of claim, affidavit, reports, and tax returns where loss of earning capacity is relied on

AI must not

  • Must not write the affidavit, or any outline of it. The affidavit is sworn
  • Must not write the worker's acknowledgment, or sign it
  • Must not choose the serious-injury limb or draft the statement of claim
  • Must not describe Form B or Form C. Those PDFs were not opened

The lawyer checks

  • The application is under section 328 of the Workplace Injury Rehabilitation and Compensation Act 2013 or section 134AB(4) of the Accident Compensation Act 1985
  • Part B: if the worker has accepted an impairment determination, attach the notice of acceptance the Ministerial Direction requires
  • Part C: if there is no deemed serious injury under section 335(1) or section 134AB(15), the limb relied on is specified
  • Part E matches the common law page: affidavit, relevant medical reports, tax returns or other proof of earnings for the three years before injury to the application date, signed Form D, and a statement of claim complying with Order 13 and Rule 13.10
  • Where loss of earning capacity is relied on, the returns include each partnership, corporation or trust in which the worker has a material interest, or other proof if returns cannot be obtained
  • Incomplete applications can be returned or suspended under Ministerial Direction 19
  • Service: if the employer is not a self-insurer, address it to the Director, Dispute Management Division, WorkSafe Victoria, by the Common Law Hub, registered post to PO Box 279, Geelong VIC 3220, or hand delivery at 1 Malop Street, Geelong, in business hours. A self-insurer receives it directly
  • The response is due in writing within 120 days of receipt unless extended. Court proceedings, if offers do not resolve the claim, are not earlier than 21 days and not more than 51 days after the statutory counter offer
  • 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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