application for compensation

This application is for people who have been medically examined and diagnosed with, or suspected to have, a compensable dust disease as a result of exposure to a hazardous dust while employed in NSW.

If you would like to make an application but you're not sure how to use our online form, please contact us This link will open in a new window. We can assist you to complete an application form, arrange necessary medical examinations and paperwork for us to assess your application.

Completing this application

If you are unable to complete this form or you need an interpreter please contact us This link will open in a new window.

Our team are available to answer any questions you have about this form or the compensation benefits that you or your eligible dependents are entitled to. We can also assist you complete this form if needed.

Please be aware that we can only deal directly with you, your appointed Power of Attorney or any authorised person that you have listed in your application form for all matters relating to your application and claim for compensation.

application for compensation

Your Personal Details

If you have any documents regarding your identity please upload them as they can assist in processing your application more quickly.

Have you been diagnosed with a dust disease?

Please note that pleural plaques are not considered a dust disease.

Please complete a Request for Medical Examination form if you have pleural plaques.

Please tick the appropriate disease boxes

Your details

Gender
Preferred method of contact*Required field
Do you have any access requirements in making this application?

For example: language interpreter, hearing impairment, disability or health issues, cultural, religious.


application for compensation

Your dependants

If you have any documents regarding your dependants (e.g. marriage certificate, birth certificate of dependant children) please upload them as they can assist in processing your application more quickly.

Do you have any dependants? Includes married and de facto partners and children

Your authorised person(s)

Please list all person(s) you authorise to provide and receive information from us on your behalf.
If you nominate your lawyer as an authorised person, please also include at least one other person.



application for compensation

Your employers and dust exposure

If you have any documents regarding your income or employment, please upload them as they can assist in processing your application more quickly.

Please list all your past employments, including all employments where you had or think you had exposure to hazardous dusts.

If there are more than 5 employers, please upload a list on the supporting documents page or these can be provided at a later date.



Your treating doctors

If you have any documents regarding your medical information please upload them as they can assist in processing your application more quickly.

If there are more than 5 doctors, please upload a list on the supporting documents page or these can be provided at a later date.

Remove doctor
Treating doctor


application for compensation

Upload supporting documents

You can submit this form without any supporting documents. One of our team will contact you to complete the application with you or your authorised person.

Please do not upload files larger than 10 MB, digital X-rays or CT scans. A DDC staff member will contact you to arrange collection of this information at a later date.

You can upload documents in PDF, JPEG, PPT, DOC, or XLS formats.

If you have any documents regarding your identity, income, dependency, medical information or employment, please upload them as they can assist in processing your application more quickly.

You can upload the following documents:

  • Identity, Income & Dependency

    Includes, but not limited to, driver license, pension card, medicare card and/or income statements.


  • Employment

    Any documents that verify your past employment.


  • Medical

    Includes doctor's letters and reports.



 

application for compensation

Review application

Please review your information you have entered. Once you're happy with it press submit.



Declaration

  • Privacy Notice

    Personal and health information is collected about you on this form and may also be collected during the processing, assessing and management of your claim. It may be collected from your current and previous employers, other government agencies, health service providers and other persons who can provide information relevant to the claim.

    Personal and health information is collected for the purposes of enabling icare Dust Diseases Care to process, assess and manage your claim and to verify any evidence you may submit in support of a claim or to assist icare Dust Diseases Care to better manage claims generally. By submitting this application you are taken to consent to this privacy notice. If you require further information on how we collect, use, store and dispose of your personal and health information please visit the icare Privacy Policy on our website.

Consent

By checking the box below, I declare that I believe the answer to each and every question on this form and the particulars contained therein or attached hereto to be true. I make this declaration in the knowledge that I am subject to punishment by law under the Workers' Compensation (Dust Diseases) Regulation 2013 for the making or signing of a statement that I know to be false or misleading in a material particular.


Thanks.

We've received your preliminary information on:
.

Here’s your application number: 012347389.
Our team will get back to you very soon.


What happens next?

Your application will be registered and one of our team members will contact you to discuss your application. We will then determine what, if any, further medical information or supporting documents are required to process your claim.

In most cases we will also require the preparation of an Industrial History Statement and/ or an Industrial History report. Your icare Customer Liaison is here to help and will guide you through these requirements.

What is an Industrial History Statement and Report?

An Industrial History Statement outlines all of your employment and dust exposure history. One of our specialised Industrial History Officers will discuss this with you over the phone or if you prefer, they can visit you to discuss this in person.

The Industrial History Officer will prepare the statement and send a copy to you to review and sign. They will also try to verify some of your employments and locate recorded corroboration for your reported exposures, which they will outline in a separate Industrial History Report.

How will my claim be determined?

icare will provide the Medical Assessment Panel with your supplied medical information, supporting documents and an Industrial History Statement and/or Report. This information will be used to confirm whether you have a compensable dust disease and, if so, what your level of disability is and how much of your disease is related to your exposure to dust in employment in NSW.

Your assigned icare Customer Liaison will be in contact with you during the application process and they will contact you as soon as your claim has been determined.