Claims

Claim forms

• Notify us of an injury by fax or email

  Use this form if an employee sustains a work-related injury and has not completed a claim form. This ‘initial notification of injury’ form can be downloaded and sent to us via email or fax. You can also lodge the claim with our online form.
  Club Employers Mutual Form – Initial Notification of Injury

• Injury claim form to be completed by worker

  Use this form to make a workers’ compensation claim for weekly payments or medical, hospital and rehabilitation expenses.
  SIRA – Worker’s injury claim form

• Other work related injury claim form to be completed by worker

  Use this form to provide additional information if you were injured during a work-related journey or during a recess or authorised absence from work.
  SIRA – Other work related injury claim form

• SIRA Standards of Practice

  SIRA has developed these Standards to support and encourage insurers to have effective claims management practices that will help deliver positive experiences and outcomes for workers, employers and the people of NSW.
  SIRA Standards of Practice

Guides for workers compensation

• Workers Compensation Guidelines

  Here the State Insurance Regulatory Authority (SIRA) details requirements, information and guidance for workers, employers, insurers and other stakeholders.
  Workers Compensation Guidelines

• Employer’s workers compensations obligations

  The State Insurance Regulatory Authority (SIRA) has produced this guide to explain an employer’s obligations under workers compensation legislation. It contains practical advice for achieving the best outcomes for both workers and employers.
  A Workers Compensation Guide for Employers

• SafeWork Australia’s notifying fact sheet

  This information sheet provides general guidance on mandatory reporting requirements for ‘notifiable incidents’ under Work Health and Safety (WHS) legislation i.e. incidents that involve a death, ‘serious’ injury or ‘dangerous occurence’.
  SafeWork Australia’s notifying fact sheet

• Injury Management Program

  Our Injury Management Program ensures our injury management approach and practices are structured, integrated and consistent to achieve best practice outcomes for all parties involved.
  Club Employers Mutual – Injury Management Program

Documents to help employer’s plan a return to work

• Employer’s return to work program, more than 20 workers

  This standard RTW program can be adopted by employers insured with CEM who employ more than 20 workers.
  Club Employers Mutual – Return to Work (RTW) Program – Category 1 Employers

• Employer’s return to work program, less than 20 workers

  This standard RTW program can be adopted by employers insured with CEM who employ less than 20 workers.
  Club Employers Mutual – Return to Work (RTW) Program – Category 2 Employers

• Return to work plan – standard

  Use this template to develop a simple return to work (RTW) plan for a worker. This is a formal document individualised for the worker, outlining the RTW goal, fitness for work and a list of duties they have the certified capacity to perform. The RTW plan will need to be updated regularly to comply with conditions or upgrades in the worker’s capacity outlined in the most recent workers compensation medical certificate.
  Club Employers Mutual Form – Return to Work (RTW) Plan – Standard

• Return to work plan – detailed

  Use this template to develop a detailed staged return to work (RTW) plan for a worker. This is a formal document individualised for the worker, outlining the RTW goal, fitness for work, list of duties they have the certified capacity to perform and treatment details. This template enables you to plan a gradual increase in duties/hours with the worker and their treating doctor. RTW plans must be signed off by the doctor before duties should be changed.
  Club Employers Mutual Form – Return to Work (RTW) – Graded

• Return to work sample plan – detailed sample

  This is an example of a completed Graded Return to Work (RTW) Plan.
  Club Employers Mutual Form – Return to Work (RTW) – Graded – EXAMPLE

Documents to assist with payments and reimbursements

• Electronic Funds Transfer (EFT)

  This form can be used by workers, employers or service providers wishing to receive claim related payments via EFT.
  Club Employers Mutual Form – Electronic Funds Transfer (EFT) Request – Claim Payments

• Pre-injury Average Weekly Earnings (PIAWE) Agreements

  This form can be used by workers, employers or service providers wishing to receive claim related payments via EFT.
  This video explains PIAWE agreements and how to enter into a PIAWE agreement for a COVID-19 claim.
  This brief guide explains how to calculate PIAWE for a PIAWE agreement.
  SIRA PIAWE Agreement Form – please use this form to enter a PIAWE agreement for non-COVID-19 claims

• Average weekly earnings (to be completed by employer)

  Use this form to provide us with details of a worker’s earnings so we can calculate their Pre-Injury Average Weekly Earnings.
  Club Employers Mutual Form – PIAWE Details

• Claim travel expenses (to be completed by worker)

  If you are a worker, use this form to make a claim for travel expenses incurred in relation to your claim.
  Club Employers Mutual Form – Claim Travel Expense Reimbursement

Forms to provide more information regarding a claim

• Witness statements

  Use this form to collect statements from witnesses of an incident.
  Club Employers Mutual Form – Statement of Witness to an Injury

• Withdraw claim (to be completed by worker)

  If you are a worker withdrawing your claim, use this form to confirm your decision.
  Club Employers Mutual Form – Letter of Authority to Withdraw Claim

• Statutory Declaration

  Use this form to provide a written statement which needs to be signed and declared true before an authorised witness. This statutory declaration is used to legally verify the following information: a worker’s employment and income status, dependents status, incident details, litigation status.
  Club Employers Mutual Form – Statutory Declaration

• Consent to obtain medical information (to be completed by worker)

  If you are a worker, complete this form to provide consent to obtain medical information.
  Club Employers Mutual Form – Letter of Authority to Release Docs & Info

• Job Seeking Log

  Complete this form as evidence of a worker’s progress with obtaining new employment.
  Club Employers Mutual Form – Job Seeking Log