Form · Personal Injury & Compensation

WorkSafe worker's claim for impairment benefits: completion guide

Link to the WorkSafe form a worker uses to claim compensation for permanent impairment from a work injury, which the claims manual treats as a non-economic loss claim.

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 claiming impairment benefits for a work injury. The worker completes and signs the current PDF. This is not the older claim for compensation for permanent disability, and it is not Form A.

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 medical reports already held for an impairment claim; the worker completes and signs the current PDF and the lawyer checks every figure.

AI may

Index reports already on the file that a worker's impairment claim usually relies on, with author and date
Record the claim number and the injury dates already on the file

AI must not

Must not write answers into the PDF
Must not calculate an impairment percentage or choose a table
Must not write anything in a declaration or authority if the current PDF contains one. The PDF body was not opened
Must not describe the form from the page's 'What it contains' box, which talks about occupier duties and does not describe this form

The lawyer checks

The current PDF is downloaded from the WorkSafe page. The page dates the file 17 November 2022 and says it is 4 pages. Read that PDF before it is used
The claims manual describes this form as a claim for non-economic loss under section 211 of the Workplace Injury Rehabilitation and Compensation Act 2013 and sections 98C and 98E of the Accident Compensation Act 1985
The worker completes and signs it
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..

Read the full text

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read the whole precedent, with its drafting notes beside 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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