--- title: "WorkSafe Form A, application for common law damages: completion guide" url: "https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-worksafe-form-a-common-law" type: "precedent" site: "AI Law Framework" id: "a21-form-vic-worksafe-form-a-common-law" area_id: "A21" kind: "form" ai_level: "yellow" version: 1 task_ids: ["A21-T1-R5", "A21-T1-R7", "A21-T1-R8", "A21-WR20261022-1"] law_stated_as_at: "2026-10-23" --- # 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. Canonical page: https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-worksafe-form-a-common-law Law stated as at: 2026-10-23 Site index for agents: https://ailawframework.com/llms.txt ## Key facts - Kind: Form. A form to complete, or a guide to completing an official one. - Practice area: [Personal Injury & Compensation](https://ailawframework.com/precedents/personal-injury-and-compensation.md) - Jurisdictions: Victoria - AI level: Yellow. You and the tool draft together, with you directing. You check every statement you rely on. - Law stated as at: 2026-10-23 - Status: Maintained. Checked on 2026-10-23 against the official form at worksafe.vic.gov.au and the 3 authorities it cites, for Victoria. ## 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 - [Draft the pre-action notice or statutory claim form from the instructions](https://ailawframework.com/practice/personal-injury-and-compensation/draft-the-pre-action-notice-or-statutory-claim-form-from-the-instruction.md) - [Draft pleadings or points of claim from the medical chronology](https://ailawframework.com/practice/personal-injury-and-compensation/draft-pleadings-or-points-of-claim-from-the-medical-chronology.md) - [Draft medico-legal instructions and review the draft report](https://ailawframework.com/practice/personal-injury-and-compensation/draft-medico-legal-instructions-and-review-the-draft-report.md) - [Test an injury against the statutory threshold for benefits or damages](https://ailawframework.com/practice/personal-injury-and-compensation/test-an-injury-against-the-statutory-threshold-for-benefits-or-damages.md) ## 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). ## Authorities - [WorkSafe Victoria, Form A, published 29 October 2024, and the Form A PDF (opened 23 October 2026)](https://www.worksafe.vic.gov.au/resources/form-application-common-law-damages-approved-worksafe-victoria-form) - [WorkSafe Victoria, Common law claim for damages, Ministerial Directions effective 1 November 2024 (opened 23 October 2026)](https://www.worksafe.vic.gov.au/common-law-claim-damages) - [Workplace Injury Rehabilitation and Compensation Act 2013 (Vic), version 054, in force 2 October 2026](https://www.legislation.vic.gov.au/in-force/acts/workplace-injury-rehabilitation-and-compensation-act-2013/054) ## Official form [Official form](https://www.worksafe.vic.gov.au/resources/form-application-common-law-damages-approved-worksafe-victoria-form) ## 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. ## Full text and drafting notes The full text and the drafting notes are not part of this public page. Signed-in firm accounts can read them at https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-worksafe-form-a-common-law and through the signed-in MCP connector https://ailawframework.com/mcp/firm. *Practice guidance for planning and review. Confirm current primary sources and the requirements of the actual matter. This is general information, not legal advice.*