ࡱ> %` jbjbj"x"x ^@@Y dTXXXXY>i[zaaaakbIdeeLNNNNNN$9hrjikbkbjijiraa#llljiaaLljiLllRTa[ XiLHP90ifi<efrlg\cgeeerrleeeijijijiji>>>#B:>>>B:NDT  Employers Report following a Workers Compensation Claim in the case of Death Workers Rehabilitation and Compensation Act To the Employer ( Fill in this claim form if you have received a workers compensation claim following the death of a worker ( Send the original of this report together with the original of the claim form to the insurance company immediately ( Keep a copy of this report and the claim form for your records Help You can get help and more information from NT WorkSafe First Floor Darwin Plaza Building 41 Smith Street, The Mall Darwin NT 0800 Phone: 08 8999 5585 Australia-wide toll free number 1800 250 713 Website:  HYPERLINK "http://www.worksafe.nt.gov.au" www.worksafe.nt.gov.au Email:  HYPERLINK "mailto:ntworksafe@nt.gov.au" ntworksafe@nt.gov.au Insurer Claim Number  Employer detailsBusiness name and address for correspondence  FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Telephone:  FORMTEXT      Name of the person who can be contacted in relation to this report Name:  FORMTEXT      Position in Company:  FORMTEXT       Insurance detailsWhat is your workers compensation insurer s name?  FORMTEXT      What is the policy number?  FORMTEXT      What is the expiry date of this policy?  FORMTEXT       About the deceased workerWorkers name Surname or family name  FORMTEXT      First or given names  FORMTEXT      Sex:  FORMCHECKBOX  Male  FORMCHECKBOX  Female Home address  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT      Date of birth  FORMTEXT      Where did the worker normally work? See Note 1 on the back  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       NT WorkSafe Claim Number / Insurer Use Only How many people are employed at this location? Number:  FORMTEXT      When was the worker first employed by you? Date:  FORMTEXT      Did the worker provide you with an Australian Business Number (ABN) in writing?  FORMCHECKBOX  No  FORMCHECKBOX  Yes When did the worker stop work following the injury or disease which led to death? Date:  FORMTEXT      Time:  FORMTEXT      Occupation at the time of injury or death? Include also the main job that was done.  FORMTEXT      In what type of industry was the worker employed? See Note 2 on the back  FORMTEXT       About the incidentWas there a major event where more than one person was injured or killed eg. fire, explosion?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Please describe what happened including the date and address where this happened. FORMTEXT       Reportable incident?Was this incident reported to NT WorkSafe as a notifiable incident? See Note 3 on the back  FORMCHECKBOX  No  FORMCHECKBOX  Yes If Yes, date notified:  FORMTEXT       About this claimIs this claim about a death related to disease?  FORMCHECKBOX  No Go to question 20  About the deceased worker s injury  FORMCHECKBOX  Yes Go to question 24  About the deceased worker s disease About the deceased workers injuryWhere did the injury happen? A  FORMCHECKBOX  While working at usual workplace B  FORMCHECKBOX  While working elsewhere C  FORMCHECKBOX  While having a break D  FORMCHECKBOX  Travelling to or from work  FORMCHECKBOX  Other See Note 4 on the back  FORMTEXT      Tell us the exact location or address where the injury happened?  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT      When did the injury happen? Date:  FORMTEXT      Time:  FORMTEXT      Please tell us: about all the events which led to the injury what the worker was doing at the time how the injury happened  FORMTEXT      Now go to Question 25 About the worker s diseaseIs this report about a work related disease which led to death?  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FORMTEXT       WitnessesDid anyone see what happened to the worker?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Give the name and address of people who saw what happened. FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT      Was the injury reported to you or a member of your staff?  FORMCHECKBOX  No Reason:  FORMTEXT        FORMCHECKBOX  Yes Date injury / disease was reported:  FORMTEXT      Time injury / disease was reported:  FORMTEXT        FORMCHECKBOX  am  FORMCHECKBOX  pmName of the person who received the report:  FORMTEXT      Position in the company:  FORMTEXT      Was the deceased off work for any period prior to death which may be due to this injury or disease?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Period off work: from  FORMTEXT       to  FORMTEXT      Did the deceased receive any compensation payments for this period?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Amount received:  FORMTEXT       DeclarationI declare that the information I have shown in this form is true and correct and I have told you everything I know about the circumstances relating to the worker s injury or disease which led to death. Signature: Date: FORMTEXT       Name of the person who received the report:  FORMTEXT      Position in the company:  FORMTEXT       Notes on Claim Form The Worker Note 1 Your answer here must tell us the actual address of the place where the deceased did the majority of his or her work. Note 2 You must state the main type of activity, business or service you provide in which the deceased worker was involved. You do not put the actual occupation of the deceased. eg If you are a gold mining company and the deceased worker was a driver, you would put down  gold mining . Note 3  Obligation to report incidents / accidents under the Workplace Health and Safety Act Section 65 of the Workplace Health and Safety Act requires that an accident or occurrence causing the death of a person be reported to NT WorkSafe as soon as practicable of its occurrence by phoning 1800 019 115. A written notification report of the incident, in an approved form (FM137), must also be provided to NT WorkSafe within 48 hours of its occurrence. Note 4 If your answer is  other please specify the deceased s activity in the space provided on the form, such as  travelling to / attendance at training school ,  travelling to / attendance at medical centre or  travelling between employer s premises (if the deceased had more than one job).     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