--- title: "WorkSafe worker's injury claim form: completion guide" url: "https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-worksafe-injury-claim" type: "precedent" site: "AI Law Framework" id: "a21-form-vic-worksafe-injury-claim" area_id: "A21" kind: "form" ai_level: "yellow" version: 1 task_ids: ["A21-T1-R5", "A21-A20260923-1", "A21-T1-R15", "A21-WR20261022-12"] law_stated_as_at: "2026-10-23" --- # WorkSafe worker's injury claim form: completion guide > Guide to the WorkSafe worker's injury claim form, in myWorkSafe or as a PDF, including the certificate of capacity, the signed medical authority and declaration, and mental-injury rules from 31 March 2024. Canonical page: https://ailawframework.com/precedents/personal-injury-and-compensation/form-vic-worksafe-injury-claim 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 weekly payments or medical and like expenses for a work injury in Victoria. The worker completes the official form and gives it to the employer, unless direct lodgement applies. For a death, use the work-related death claim form. ## 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) - [Reconcile the claim form with the medical chronology and payroll evidence](https://ailawframework.com/practice/personal-injury-and-compensation/reconcile-the-claim-form-with-the-medical-chronology-and-payroll-evidenc.md) - [Triage a new injury enquiry against scheme eligibility](https://ailawframework.com/practice/personal-injury-and-compensation/triage-a-new-injury-enquiry-against-scheme-eligibility.md) - [Record the time to give notice of a statutory-benefits claim](https://ailawframework.com/practice/personal-injury-and-compensation/record-the-time-to-give-notice-of-a-statutory-benefits-claim.md) ## How AI may be used The tool may list the documents the worker still needs and diary the certificate and deeming dates the lawyer confirms; the worker completes and signs the official form. **AI may:** - List injuries already named on the file so the lawyer can check each one is on the certificate of capacity - Note whether the claim includes a mental injury and whether the injury date is before or after 31 March 2024 - Diary the date a valid certificate reaches the agent, because the claims manual ties the 28-day deeming clock to that date **AI must not:** - Must not write the worker's answers, or sign the authority to release medical information and declaration - Must not decide that a mental injury is compensable, or that management action was unreasonable - Must not treat help filling in the form as lodgement - Must not state a time limit for lodging the claim. The pages opened do not give one **The lawyer checks:** - Questions 1 to 6 of Part A are the worker's. The employer completes question 7 and Part B, unless direct lodgement applies - A PDF or paper form is signed at the authority and declaration. On myWorkSafe the claims manual treats the form as electronically signed on submission - Every injury on the form is on the certificate of capacity. For weekly payments the certificate meets the claims manual's section 25 points - For a mental injury on or after 31 March 2024, the certificate uses the latest DSM and states significant behavioural, cognitive or psychological dysfunction - Provisional payments for a mental injury: the agent usually answers within 5 business days, and if the claim is rejected may cover reasonable treatment for up to 13 weeks - 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 injury claim form (opened 23 October 2026)](https://www.worksafe.vic.gov.au/workers-injury-claim-form) - [WorkSafe claims manual, Worker completes claim form, citing the Workplace Injury Rehabilitation and Compensation Act 2013 ss 20 and 25](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/workers-injury-claim-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-injury-claim 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.*