ࡱ> %` &bjbj"x"x a@@p( u2222db4"Y.` h<# $)h|22_ΫΫΫ.28ΫΫΫXlj" e7.*4 )0YT4 CrΫU\CCCCCCY"""8N[d3"""N[T:h222222  Workers Compensation Claim Form in the case of Death Workers Rehabilitation and Compensation Act To the person filling in this form ( Fill in this claim form if you were dependent on someone who died following a work related injury or disease ( When you have filled in this form give it to the deceaseds employer as soon as possible ( Keep a copy of 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 Stamp  About the deceased1. Surname or family name  FORMTEXT      First or given names  FORMTEXT      2. Sex:  FORMCHECKBOX  Male  FORMCHECKBOX  Female 3. Home address  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT      4. Date of birth  FORMTEXT      5. Date of death  FORMTEXT      6. Occupation at the time of injury or disease which led to death. Include here the main job that was done  FORMTEXT       7. Employers business name, address and telephone number  FORMTEXT        FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Telephone:  FORMTEXT      8. Where did the deceased normally work? See Note 1 on the back  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       About the claim9. Did the death follow a work related disease?  FORMCHECKBOX  No Go to Question 10  About the injury  FORMCHECKBOX  Yes Go to Question 14  About the disease NT WorkSafe Claim Number / Insurer Use Only  About the injury10. Where 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 2 on the back  FORMTEXT      11. Tell us the exact location or address where the injury happened?  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT      12. When did the injury happen? Date:  FORMTEXT      Time:  FORMTEXT        FORMCHECKBOX  am  FORMCHECKBOX  pm13. 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 16 About the disease14. What date was the disease first noticed?  FORMTEXT      15. Please tell us: about all the events which led to the disease the address where the disease was contracted the main cause (eg  exposure to asbestos dust) the names of other employers the deceased worked for where the same sort of job was done  FORMTEXT       Witnesses16. Did 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      17. Was the injury or disease reported to the employer?  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 reported to:  FORMTEXT      Position in the company:  FORMTEXT      18. When did the deceased stop work because of the injury or disease? Date stopped work:  FORMTEXT      Time stopped work:  FORMTEXT        FORMCHECKBOX  am  FORMCHECKBOX  pm19. Was the deceased off work for any period prior to death due to this injury or disease?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Period off work: from  FORMTEXT       to  FORMTEXT      20. Did the deceased receive any compensation payments for this period?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Amount received:  FORMTEXT       Medical details21. What was the cause of death? Include here: part of body affected type of injury or disease agency or thing that caused the injury or disease eg grinder, drill etc. Make sure you attach the Medical Certificate and, if possible, the Death Certificate to this form.  FORMTEXT      22. Did the deceased get any medical treatment following the injury or disease?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Name and address of doctor and / or health worker FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Dates treated: from  FORMTEXT       to  FORMTEXT      23. Prior to death, was the worker admitted to a hospital or medical centre?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Name and address of hospital / medical centre FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Period of time in hospital / medical centre from  FORMTEXT       to  FORMTEXT      from  FORMTEXT       to  FORMTEXT      24. Has the deceased suffered from a similar injury or disease before?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Name of the doctor who treated the deceased  FORMTEXT       Address of the doctor FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Type of injury or disease:  FORMTEXT       When did the injury or disease occur?  FORMTEXT      25. Have there been any claims for workers compensation before?  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FORMTEXT       How long was the deceased off work:  FORMTEXT       Amount of compensation received: $  FORMTEXT      Now go to Question 26  About the dependants About the deceased worker s dependants26. Please give the following details about all the dependants of the deceased worker. If there is not enough space, writer the extra details on a separate piece of paper and attach it to this form. You must see Note 4 on the back to find out what dependant means. Surname or family name  FORMTEXT      First or given names  FORMTEXT      Home address  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Surname or family name  FORMTEXT      First or given names  FORMTEXT      Home address  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Surname or family name  FORMTEXT      First or given names  FORMTEXT      Home address  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT       Surname or family name  FORMTEXT      First or given names  FORMTEXT      Home address  FORMTEXT       FORMTEXT       FORMTEXT       Postcode:  FORMTEXT      Relationship to deceased (wife/husband/son/daughter etc)  FORMTEXT       Date of birth of this dependant? FORMTEXT      Is this dependant a student?  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  Full time  FORMCHECKBOX  Part time Gross weekly income of this dependant$  FORMTEXT      If none, write  NONE Relationship to deceased (wife/husband/son/daughter etc)  FORMTEXT       Date of birth of this dependant? FORMTEXT      Is this dependant a student?  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  Full time  FORMCHECKBOX  Part time Gross weekly income of this dependant$  FORMTEXT      If none, write  NONE Relationship to deceased (wife/husband/son/daughter etc)  FORMTEXT       Date of birth of this dependant? FORMTEXT      Is this dependant a student?  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  Full time  FORMCHECKBOX  Part time Gross weekly income of this dependant$  FORMTEXT      If none, write  NONE Relationship to deceased (wife/husband/son/daughter etc)  FORMTEXT       Date of birth of this dependant? FORMTEXT      Is this dependant a student?  FORMCHECKBOX  No  FORMCHECKBOX  Yes  FORMCHECKBOX  Full time  FORMCHECKBOX  Part time Gross weekly income of this dependant$  FORMTEXT      If none, write  NONE Notes on Claim Form Note 1 Your answer here must tell us the actual address or location of the place where the deceased did the majority of his or her work. Note 2 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). Note 3 This information is required to determine if the injury or disease led to death may be related to a previous incident. Note 4 Definition of Dependant Dependants of a deceased worker are basically the family and spouse of that worker who are partly or wholly dependant on the worker s earnings at the date of the worker s death. A spouse is the husband or wife of the deceased worker.  Spouse also includes defacto partners, and if the person is an aboriginal native, can include a partner according to the customs of the deceased worker s tribe or group.  Family can include any children or grandchildren of the deceased worker. This includes children born out of wedlock, and children who are not the deceased worker s natural offspring eg adopted children. Similarly,  family can also include any parent or grandparent of the deceased worker even though the deceased worker was born out of wedlock or was not the parent s natural offspring. If the person is an aboriginal native, family can include all persons who are members of the deceased worker s family according to customs of the deceased worker s tribe or group.     FM4001  PAGE 1 Declaration27. I declare that all the information I have shown in this report is true and correct and I have told you everything I know about the circumstances relating to the work related injury or disease which led to the death of the worker. 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