Official form guide
Form IISBN-Workers-claim-for-impairment-benefits-form-2022-11-02: IISBN-Workers-claim-for-impairment-benefits-form-2022-11-02
The WorkSafe Victoria Worker’s Claim for Impairment Benefits form is used to apply for impairment benefits after a work‑related injury or condition. It must be completed by the worker and signed by the employer.
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Form Overview
WorkSafe Victoria Form IISBN-Workers-claim-for-impairment-benefits-form-2022-11-02 - IISBN-Workers-claim-for-impairment-benefits-form-2022-11-02
The WorkSafe Victoria Worker’s Claim for Impairment Benefits form is used to apply for impairment benefits after a work‑related injury or condition. It must be completed by the worker and signed by the employer.
Risk Radar
Scan points- 1Most workers forget to ensure the employer forwards the form within 10 days.
- 2Employer signature missing
- 3Medical release not signed
- 4Insufficient space for answers without attachments
- 5Employer does not forward within 10 days
Plain English
If you’ve been hurt at work and need impairment compensation, you fill out this form and give it to your employer. The employer then sends it to WorkSafe Victoria for processing.
Submission Date
- Filing date: Give the form to your most recent employer as soon as you decide to claim; the employer must forward it to the WorkSafe Agent within 10 days of receipt.
- Preparation window: collect IDs, supporting records, and signatures in advance.
- Final review: verify names, dates, and required fields before submission.
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What this form is for
- You have a permanent impairment from a work‑related injury that has stabilised.
- At least 12 months have passed since the injury (or you are over 18 if you were a minor).
- All injuries from the same work event are being claimed on one form.
- You need to provide your employer’s WorkSafe Agent with the completed form.
- You must sign the medical‑information release and worker’s declaration.
Form selector
Use this form or another form?
Injury less than 12 months old
May need a standard workers compensation claim form
✓ Confirm injury stabilisation before using this form
Claim for weekly payments or medical expenses only
Different form covers non‑impairment benefits
✓ Check if impairment benefits are required
Employer is a self‑insurer
Form references ‘self‑insurer’ language
✓ Verify whether the employer is an approved self‑insurer
Deadline or filing window
The employer must forward the form to the WorkSafe Agent within 10 days of receiving it; otherwise the claim may be delayed or returned.
Before you submit
- 1All personal detail fields are filled in, including preferred contact method.
- 2Every injury/condition is listed with body part, date and location.
- 3Previous workers‑compensation claims are disclosed if applicable.
- 4Medical‑information release is signed and dated.
- 5Employer section (Section 8) is fully completed and signed.
- 6Attach any extra notes if space on the form is insufficient.
- 7Make a copy of the completed form for your records.
- 8Serve the form to your employer (most recent employer if multiple).
- 9If employer does not forward within 10 days, send directly to the WorkSafe Agent.
How to file this form
- 1Complete your personal details and injury circumstances on pages 1‑2.
- 2Sign the authority to release medical information on page 3.
- 3Give the form to your employer (or most recent employer).
- 4Ask the employer to complete Section 8 and forward the form to their WorkSafe Agent within 10 days.
- 5If the employer cannot forward, send the form yourself to the WorkSafe Agent or WorkSafe.
- 6Keep a copy of the signed form and any attachments.
Known limitations
- 1Form only covers permanent impairment benefits, not weekly or medical expense claims.
- 2Cannot be used if the injury has not stabilised or is less than 12 months old (unless approved).
- 3Employer must forward the form within 10 days; otherwise the claim may be delayed.
- 4Incomplete forms may be returned for correction.
Field map
Compact field-by-field guide
Worker
1 items
Name, contact details, and date of birth of the injured worker.
Employer
1 items
Employer name and workplace where the injury happened.
Injury
1 items
How, when, and where the injury or illness occurred.
Medical
1 items
Attach the Certificate of Capacity from your treating practitioner where required.
Declaration
1 items
Sign and date the claim, then give it to your employer or WorkSafe agent.
Almost done reviewing the fields?
Fillable formOpen in Editor->This is the 2022‑11‑02 version of WorkSafe Victoria’s Worker’s Claim for Impairment Benefits form and remains the current form for permanent impairment claims.
What changed or needs a fresh check
- Confirm the form is dated 2022‑11‑02.
- Use dark blue or black pen as instructed.
- Check that Section 8 (Employer completion) is present.
- Verify the privacy policy link points to worksafe.vic.gov.au.
- Ensure the worker’s signature block includes date fields.
Quick Facts
Sources
- SRCForm is for a worker to claim compensation for permanent impairment (p.1).
- SRCClaim should not be made less than 12 months after injury unless stabilised (p.1).
- SRCMinor must wait until 18 years of age (p.1).
- SRCForm must be completed using dark blue or black pen (p.1).
- SRCEmployer must complete Section 8 and forward to WorkSafe Agent within 10 days (p.1).
- SRCWorker must sign authority to release medical information (p.3).
- SRCPrivacy policy is available at worksafe.vic.gov.au (p.4).
- SRCIf employer refuses or cannot forward, worker may send directly to WorkSafe Agent (p.1).
Common confusion points
When to claim – many think they can claim immediately after injury.
Whether to include injuries from separate work events on the same form.
Using the wrong pen colour leading to a rejected form.
Forgetting to sign the medical‑information release authority.
Not giving the form to the most recent employer when multiple employers are involved.
Assuming the employer will automatically forward the form without confirming the 10‑day deadline.
Misunderstanding the self‑insurer wording on page 4.
Source transparency
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