---
title: "WorkSafe worker's claim for impairment benefits: completion guide"
url: "https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-worksafe-impairment-benefits"
type: "precedent"
site: "AI Law Framework"
id: "a21-form-vic-worksafe-impairment-benefits"
area_id: "A21"
kind: "form"
ai_level: "yellow"
version: 1
task_ids: ["A21-B8-2", "A21-WR20261022-1", "A21-T1-R3", "A21-T1-R4"]
law_stated_as_at: "2026-10-23"
---

# 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.

Canonical page: https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-worksafe-impairment-benefits  
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 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

- [Summarise medical reports for a whole-person impairment assessment](https://ailawframework.com/practice/personal-injury-and-compensation/summarise-medical-reports-for-a-whole-person-impairment-assessment.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)
- [Prepare a damages or statutory-entitlements schedule](https://ailawframework.com/practice/personal-injury-and-compensation/prepare-a-damages-or-statutory-entitlements-schedule.md)
- [Map statutory entitlements under the applicable compensation scheme](https://ailawframework.com/practice/personal-injury-and-compensation/map-statutory-entitlements-under-the-applicable-compensation-scheme.md)

## 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).

## Authorities

- [WorkSafe Victoria, Worker's claim for impairment benefits form, published 17 November 2022 (opened 23 October 2026)](https://www.worksafe.vic.gov.au/resources/workers-claim-impairment-benefits-form)
- [WorkSafe claims manual, approved forms, Worker's Claim for Impairment Benefits, citing Workplace Injury Rehabilitation and Compensation Act 2013 s 211 and Accident Compensation Act 1985 ss 98C and 98E](https://www1.worksafe.vic.gov.au/vwa/claimsmanual/Claims%20Manual/2-claims-management/2-2-make-claim/2-2-1-worker-completes-claim-form.htm)
- [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/workers-claim-impairment-benefits-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-impairment-benefits 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.*