urlscan.io logo urlscan.io
SecurityTrails logo

apply-work-injury.claim-mate.com Open in urlscan Pro
45.63.29.1  Public Scan

Back to summary
URL: https://apply-work-injury.claim-mate.com/
Submission: On August 08 via automatic, source certstream-suspicious — Scanned from AU

Form analysis 1 forms found in the DOM

POST #

<form action="#" class="form" id="form" method="post" autocomplete="on" novalidate="novalidate">
  <div id="step1" class=" form-step step-item">
    <h2 class="step_heading">Have you or someone you know suffered an injury or illness while at work, or because of work?</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-12">
          <input type="radio" id="injury1" value="Yes" name="injury" data-format="radio" class="option-radio  ">
          <label for="injury1" class="btn btn-block btn-radio hvr-grow injury1" id="select-option">Yes</label>
        </div>
        <div class="col-md-12">
          <input type="radio" id="injury2" value="No" name="injury" data-format="radio" class="option-radio  ">
          <label for="injury2" class="btn btn-block btn-radio hvr-grow injury2" id="select-option">No</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step1">
          <!-- NEXT | SUBMIT -->
          <div class="col-12">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step2" class="d-none form-step step-item">
    <h2 class="step_heading">What state were you working in when you sustained the injury or illness</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-12">
          <div class="input-box py-2">
            <select name="incident_location" id="incident_location" class="form-control form-custom custom-select  " required="required" aria-required="true">
              <option value="" selected="" disabled="" hidden=""></option>
              <option value="Queensland">Queensland</option>
              <option value="New South Wales">New South Wales</option>
              <option value="Victoria">Victoria</option>
              <option value="Australian Capital Territory">Australian Capital Territory</option>
              <option value="Western Australia">Western Australia</option>
              <option value="Tasmania">Tasmania</option>
              <option value="South Australia">South Australia</option>
              <option value="Northern Territory">Northern Territory</option>
              <option value="Outside of Australia">Outside of Australia</option>
            </select>
            <label for="incident_location">Select your State</label>
          </div>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step2">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
            <button type="button" class="next-link float-right">Next </button>
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step3" class="d-none form-step step-item">
    <h2 class="step_heading">How long ago did the work accident occur?</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="radio" id="recent_injury1" value="1 year or less" name="recent_injury" data-format="radio" class="option-radio  ">
          <label for="recent_injury1" class="btn btn-block btn-radio hvr-grow recent_injury1" id="select-option">1 year or less</label>
        </div>
        <div class="col-md-6">
          <input type="radio" id="recent_injury2" value="1 year or more" name="recent_injury" data-format="radio" class="option-radio  ">
          <label for="recent_injury2" class="btn btn-block btn-radio hvr-grow recent_injury2" id="select-option">1 year or more</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step3">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step4" class="d-none form-step step-item">
    <h2 class="step_heading">What type of medical attention have you sought because of the work injury or illness? </h2>
    <h4 class="text-center my-3 head_multiple"><i>Can select multiple answers</i></h4>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="checkbox" id="medical_attention1" value="Physiotherapy" name="medical_attention_item[]" data-format="checkbox" class="option-radio  ">
          <label for="medical_attention1" class="btn btn-block btn-checkbox hvr-grow medical_attention1" id="select-option">Physiotherapy</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="medical_attention2" value="Surgery" name="medical_attention_item[]" data-format="checkbox" class="option-radio  ">
          <label for="medical_attention2" class="btn btn-block btn-checkbox hvr-grow medical_attention2" id="select-option">Surgery</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="medical_attention3" value="General Practice" name="medical_attention_item[]" data-format="checkbox" class="option-radio  ">
          <label for="medical_attention3" class="btn btn-block btn-checkbox hvr-grow medical_attention3" id="select-option">General Practice</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="medical_attention4" value="Occupational Therapy" name="medical_attention_item[]" data-format="checkbox" class="option-radio  ">
          <label for="medical_attention4" class="btn btn-block btn-checkbox hvr-grow medical_attention4" id="select-option">Occupational Therapy</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="medical_attention5" value="Other" name="medical_attention_item[]" data-format="checkbox" class="option-radio  ">
          <label for="medical_attention5" class="btn btn-block btn-checkbox hvr-grow medical_attention5" id="select-option">Other</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="medical_attention6" value="None" name="medical_attention_item[]" data-format="checkbox" class="option-radio  ">
          <label for="medical_attention6" class="btn btn-block btn-checkbox hvr-grow medical_attention6" id="select-option">None</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step4">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
            <button type="button" class="next-link float-right">Next </button>
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step5" class="d-none form-step step-item">
    <h2 class="step_heading">Are you currently working?</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="radio" id="working1" value="Yes" name="working" data-format="radio" class="option-radio  ">
          <label for="working1" class="btn btn-block btn-radio hvr-grow working1" id="select-option">Yes</label>
        </div>
        <div class="col-md-6">
          <input type="radio" id="working2" value="No" name="working" data-format="radio" class="option-radio  ">
          <label for="working2" class="btn btn-block btn-radio hvr-grow working2" id="select-option">No</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step5">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step6" class="d-none form-step step-item">
    <h2 class="step_heading">Have you incurred any medical expenses because of work-related injury or illness?</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="radio" id="medical_expenses1" value="Yes" name="medical_expenses" data-format="radio" class="option-radio  ">
          <label for="medical_expenses1" class="btn btn-block btn-radio hvr-grow medical_expenses1" id="select-option">Yes</label>
        </div>
        <div class="col-md-6">
          <input type="radio" id="medical_expenses2" value="No" name="medical_expenses" data-format="radio" class="option-radio  ">
          <label for="medical_expenses2" class="btn btn-block btn-radio hvr-grow medical_expenses2" id="select-option">No</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step6">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step7" class="d-none form-step step-item">
    <h2 class="step_heading">Have you incurred any wage loss because of work-related injury or illness?</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="radio" id="loss_of_income1" value="Yes" name="loss_of_income" data-format="radio" class="option-radio  ">
          <label for="loss_of_income1" class="btn btn-block btn-radio hvr-grow loss_of_income1" id="select-option">Yes</label>
        </div>
        <div class="col-md-6">
          <input type="radio" id="loss_of_income2" value="No" name="loss_of_income" data-format="radio" class="option-radio  ">
          <label for="loss_of_income2" class="btn btn-block btn-radio hvr-grow loss_of_income2" id="select-option">No</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step7">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step8" class="d-none form-step step-item">
    <h2 class="step_heading">Have you taken a lump sum previously through a claim?<br><span> (E.g. With your employer and WorkCover/iCare/Insurer) </span></h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="radio" id="made_claim1" value="Yes" name="made_claim" data-format="radio" class="option-radio  ">
          <label for="made_claim1" class="btn btn-block btn-radio hvr-grow made_claim1" id="select-option">Yes</label>
        </div>
        <div class="col-md-6">
          <input type="radio" id="made_claim2" value="No" name="made_claim" data-format="radio" class="option-radio  ">
          <label for="made_claim2" class="btn btn-block btn-radio hvr-grow made_claim2" id="select-option">No</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step8">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step9" class="d-none form-step step-item">
    <h2 class="step_heading">Do you have a comcare claim?</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="radio" id="comcare_claim1" value="Yes" name="comcare_claim" data-format="radio" class="option-radio  ">
          <label for="comcare_claim1" class="btn btn-block btn-radio hvr-grow comcare_claim1" id="select-option">Yes</label>
        </div>
        <div class="col-md-6">
          <input type="radio" id="comcare_claim2" value="No" name="comcare_claim" data-format="radio" class="option-radio  ">
          <label for="comcare_claim2" class="btn btn-block btn-radio hvr-grow comcare_claim2" id="select-option">No</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step9">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step10" class="d-none form-step step-item">
    <h2 class="step_heading">What type of injuries were sustained because of work-related injury or illness?</h2>
    <h4 class="text-center my-3 head_multiple"><i>Can select multiple answers</i></h4>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury1" value="Back or neck injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury1" class="btn btn-block btn-checkbox hvr-grow type_of_injury1" id="select-option">Back or neck injury</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury2" value="Hip, knee, ankle injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury2" class="btn btn-block btn-checkbox hvr-grow type_of_injury2" id="select-option">Hip, knee, ankle injury</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury3" value="Shoulder, elbow, wrist" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury3" class="btn btn-block btn-checkbox hvr-grow type_of_injury3" id="select-option">Shoulder, elbow, wrist</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury4" value="Amputation" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury4" class="btn btn-block btn-checkbox hvr-grow type_of_injury4" id="select-option">Amputation</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury5" value="Paraplegia or <br />Quadriplegia" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury5" class="btn btn-block btn-checkbox hvr-grow type_of_injury5" id="select-option">Paraplegia or <br>Quadriplegia</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury6" value="Psychological illness<br /> or injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury6" class="btn btn-block btn-checkbox hvr-grow type_of_injury6" id="select-option">Psychological illness<br> or injury</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury7" value="Mesothelioma, <br />Silicosis or Asthma" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury7" class="btn btn-block btn-checkbox hvr-grow type_of_injury7" id="select-option">Mesothelioma, <br>Silicosis or Asthma</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury8" value="Loss of vision<br /> or hearing" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury8" class="btn btn-block btn-checkbox hvr-grow type_of_injury8" id="select-option">Loss of vision<br> or hearing</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury9" value="Head injury" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury9" class="btn btn-block btn-checkbox hvr-grow type_of_injury9" id="select-option">Head injury</label>
        </div>
        <div class="col-md-6">
          <input type="checkbox" id="type_of_injury10" value="Injury/illness not listed" name="type_of_injury_item[]" data-format="checkbox" class="option-radio  ">
          <label for="type_of_injury10" class="btn btn-block btn-checkbox hvr-grow type_of_injury10" id="select-option">Injury/illness not listed</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step10">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
            <button type="button" class="next-link float-right">Next </button>
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step11" class="d-none form-step step-item">
    <h2 class="step_heading">What is your date of birth?</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-4">
          <div class="input-box py-2">
            <select name="dob_day" id="dob_day" class="form-control form-custom custom-select  " required="required" aria-required="true">
              <option value="" selected="" disabled="" hidden=""></option>
              <option value="1">1</option>
              <option value="2">2</option>
              <option value="3">3</option>
              <option value="4">4</option>
              <option value="5">5</option>
              <option value="6">6</option>
              <option value="7">7</option>
              <option value="8">8</option>
              <option value="9">9</option>
              <option value="10">10</option>
              <option value="11">11</option>
              <option value="12">12</option>
              <option value="13">13</option>
              <option value="14">14</option>
              <option value="15">15</option>
              <option value="16">16</option>
              <option value="17">17</option>
              <option value="18">18</option>
              <option value="19">19</option>
              <option value="20">20</option>
              <option value="21">21</option>
              <option value="22">22</option>
              <option value="23">23</option>
              <option value="24">24</option>
              <option value="25">25</option>
              <option value="26">26</option>
              <option value="27">27</option>
              <option value="28">28</option>
              <option value="29">29</option>
              <option value="30">30</option>
              <option value="31">31</option>
            </select>
            <label for="dob_day">Day</label>
          </div>
        </div>
        <div class="col-md-4">
          <div class="input-box py-2">
            <select name="dob_month" id="dob_month" class="form-control form-custom custom-select  " required="required" aria-required="true">
              <option value="" selected="" disabled="" hidden=""></option>
              <option value="1">Jan</option>
              <option value="2">Feb</option>
              <option value="3">Mar</option>
              <option value="4">Apr</option>
              <option value="5">May</option>
              <option value="6">Jun</option>
              <option value="7">Jul</option>
              <option value="8">Aug</option>
              <option value="9">Sep</option>
              <option value="10">Oct</option>
              <option value="11">Nov</option>
              <option value="12">Dec</option>
            </select>
            <label for="dob_month">Month</label>
          </div>
        </div>
        <div class="col-md-4">
          <div class="input-box py-2">
            <select name="dob_year" id="dob_year" class="form-control form-custom custom-select  " required="required" aria-required="true">
              <option value="" selected="" disabled="" hidden=""></option>
              <option value="2006">2006</option>
              <option value="2005">2005</option>
              <option value="2004">2004</option>
              <option value="2003">2003</option>
              <option value="2002">2002</option>
              <option value="2001">2001</option>
              <option value="2000">2000</option>
              <option value="1999">1999</option>
              <option value="1998">1998</option>
              <option value="1997">1997</option>
              <option value="1996">1996</option>
              <option value="1995">1995</option>
              <option value="1994">1994</option>
              <option value="1993">1993</option>
              <option value="1992">1992</option>
              <option value="1991">1991</option>
              <option value="1990">1990</option>
              <option value="1989">1989</option>
              <option value="1988">1988</option>
              <option value="1987">1987</option>
              <option value="1986">1986</option>
              <option value="1985">1985</option>
              <option value="1984">1984</option>
              <option value="1983">1983</option>
              <option value="1982">1982</option>
              <option value="1981">1981</option>
              <option value="1980">1980</option>
              <option value="1979">1979</option>
              <option value="1978">1978</option>
              <option value="1977">1977</option>
              <option value="1976">1976</option>
              <option value="1975">1975</option>
              <option value="1974">1974</option>
              <option value="1973">1973</option>
              <option value="1972">1972</option>
              <option value="1971">1971</option>
              <option value="1970">1970</option>
              <option value="1969">1969</option>
              <option value="1968">1968</option>
              <option value="1967">1967</option>
              <option value="1966">1966</option>
              <option value="1965">1965</option>
              <option value="1964">1964</option>
              <option value="1963">1963</option>
              <option value="1962">1962</option>
              <option value="1961">1961</option>
              <option value="1960">1960</option>
              <option value="1959">1959</option>
              <option value="1958">1958</option>
              <option value="1957">1957</option>
              <option value="1956">1956</option>
              <option value="1955">1955</option>
              <option value="1954">1954</option>
              <option value="1953">1953</option>
              <option value="1952">1952</option>
              <option value="1951">1951</option>
              <option value="1950">1950</option>
              <option value="1949">1949</option>
              <option value="1948">1948</option>
              <option value="1947">1947</option>
              <option value="1946">1946</option>
              <option value="1945">1945</option>
              <option value="1944">1944</option>
              <option value="1943">1943</option>
              <option value="1942">1942</option>
              <option value="1941">1941</option>
              <option value="1940">1940</option>
              <option value="1939">1939</option>
              <option value="1938">1938</option>
              <option value="1937">1937</option>
              <option value="1936">1936</option>
              <option value="1935">1935</option>
              <option value="1934">1934</option>
              <option value="1933">1933</option>
              <option value="1932">1932</option>
              <option value="1931">1931</option>
              <option value="1930">1930</option>
              <option value="1929">1929</option>
              <option value="1928">1928</option>
              <option value="1927">1927</option>
              <option value="1926">1926</option>
              <option value="1925">1925</option>
            </select>
            <label for="dob_year">Year</label>
          </div>
        </div>
        <div class="col-md-12">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom  d-none" id="dob" name="dob" placeholder="">
            <label for="dob"></label>
          </div>
        </div>
        <div class="col-md-12">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom  d-none" id="age" name="age" placeholder="">
            <label for="age"></label>
          </div>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step11">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
            <button type="button" class="next-link float-right">Next </button>
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <div id="step12" class="d-none form-step step-item">
    <h2 class="step_heading">Final Step! <br>Please Fill Out Information Below so You Can Receive Your Results</h2>
    <div class="hero-form mt-sm-4 mt-3 mtmobile">
      <div class="row form-fill">
        <div class="col-md-6">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom form-name " id="first_name" name="first_name" placeholder="">
            <label for="first_name">First Name</label>
          </div>
        </div>
        <div class="col-md-6">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom form-name " id="last_name" name="last_name" placeholder="">
            <label for="last_name">Last Name</label>
          </div>
        </div>
        <div class="col-md-6">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom form-email " id="email_address" name="email_address" placeholder="">
            <label for="email_address">Email</label>
          </div>
        </div>
        <div class="col-md-6">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom form-phone " id="phone" name="phone" placeholder="" maxlength="10" minlength="10" inputmode="numeric">
            <label for="phone">Phone</label>
          </div>
        </div>
        <div class="col-md-12 d-none">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom  d-none" id="email" name="email" placeholder="">
            <label for="email">Email</label>
          </div>
        </div>
        <div class="col-md-12 d-none">
          <div class="input-box py-2">
            <input type="text" class="form-control form-custom  d-none" id="phone_home" name="phone_home" placeholder="">
            <label for="phone_home"></label>
          </div>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-12">
        <div id="address-text" style="text-align: center;"></div>
        <div class="row step12">
          <!-- Back Button -->
          <div class="col-6">
            <a class="back-link back-link-d mb-3 float-left"><img src="images/angle-left-regular.svg" width="12" class="mr-2" alt="Back"> Back</a>
          </div>
          <!-- NEXT | SUBMIT -->
          <div class="col-6">
            <input type="submit" class="action btn btn-submit float-right" id="check_eligibility" value="SUBMIT">
          </div>
        </div>
      </div>
    </div>
    <div class="form-footer mt-3">
      <p class="text-center" style="color: #838383;"> <img src="images/icon-padlock.png"><small>Confidential, Safe and Secure</small></p>
    </div>
  </div>
  <input type="hidden" id="ip_address" name="ip_address" value="66.203.112.168">
  <input type="hidden" name="landing_page" value="https://apply-work-injury.claim-mate.com">
  <input type="hidden" name="user_agent" value="Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/115.0.5790.170 Safari/537.36">
  <input type="hidden" name="lp_s1" value="">
  <input type="hidden" name="src" value="">
  <input type="hidden" id="medical_attention" name="medical_attention" value="">
  <input type="hidden" id="type_of_injury" name="type_of_injury" value="">
  <!-- Get Dynamic Parameters -->
  <input type="hidden" id="ip_flagged" name="ip_flagged" value="">
  <input type="hidden" id="brand_name" name="brand_name" value="Claim Mate">
  <!-- TrustedForm -->
  <script type="text/javascript">
    (function() {
      var tf = document.createElement('script');
      tf.type = 'text/javascript';
      tf.async = true;
      tf.src = ("https:" == document.location.protocol ? 'https' : 'http') + "://api.trustedform.com/trustedform.js?field=xxTrustedFormCertUrl&ping_field=xxTrustedFormPingUrl&l=" + new Date().getTime() + Math.random();
      var s = document.getElementsByTagName('script')[0];
      s.parentNode.insertBefore(tf, s);
    })();
  </script>
  <noscript>
    <img src="https://api.trustedform.com/ns.gif">
  </noscript>
  <!-- End TrustedForm -->
  <input type="hidden" name="xxTrustedFormToken" id="xxTrustedFormToken_0" value="https://cert.trustedform.com/4fa120cd6b5de2b869cf92e7f4b7ff7f8efac5a4"><input type="hidden" name="xxTrustedFormCertUrl" id="xxTrustedFormCertUrl_0"
    value="https://cert.trustedform.com/4fa120cd6b5de2b869cf92e7f4b7ff7f8efac5a4"><input type="hidden" name="xxTrustedFormPingUrl" id="xxTrustedFormPingUrl_0"
    value="https://ping.trustedform.com/0.pfDAMkWwZ5-V68X9ZtPd0ska1yO7jVXhkZbFtW7VicMKvUnd1DqinudtXzG8kx4EppFF5F7d.18flRpwnaY32xuI52VqqSA.421Z0k3mN6Pog9o19fna0A">
</form>

Text Content

CLAIM MATE

Check Eligibility


CLAIM MATE


HAVE YOU SUFFERED A WORK-RELATED
INJURY OR ILLNESS?


YOU MAY BE ENTITLED TO A RANGE OF COMPENSATION BENEFITS.

60 Second Eligibility Check



HAVE YOU OR SOMEONE YOU KNOW SUFFERED AN INJURY OR ILLNESS WHILE AT WORK, OR
BECAUSE OF WORK?

Yes
No

Confidential, Safe and Secure


HAVE YOU OR SOMEONE YOU KNOW SUFFERED AN INJURY OR ILLNESS WHILE AT WORK, OR
BECAUSE OF WORK?

Yes
No


Confidential, Safe and Secure


WHAT STATE WERE YOU WORKING IN WHEN YOU SUSTAINED THE INJURY OR ILLNESS

Queensland New South Wales Victoria Australian Capital Territory Western
Australia Tasmania South Australia Northern Territory Outside of Australia
Select your State
Back
Next

Confidential, Safe and Secure


HOW LONG AGO DID THE WORK ACCIDENT OCCUR?

1 year or less
1 year or more
Back


Confidential, Safe and Secure


WHAT TYPE OF MEDICAL ATTENTION HAVE YOU SOUGHT BECAUSE OF THE WORK INJURY OR
ILLNESS?

CAN SELECT MULTIPLE ANSWERS

Physiotherapy
Surgery
General Practice
Occupational Therapy
Other
None
Back
Next

Confidential, Safe and Secure


ARE YOU CURRENTLY WORKING?

Yes
No
Back


Confidential, Safe and Secure


HAVE YOU INCURRED ANY MEDICAL EXPENSES BECAUSE OF WORK-RELATED INJURY OR
ILLNESS?

Yes
No
Back


Confidential, Safe and Secure


HAVE YOU INCURRED ANY WAGE LOSS BECAUSE OF WORK-RELATED INJURY OR ILLNESS?

Yes
No
Back


Confidential, Safe and Secure


HAVE YOU TAKEN A LUMP SUM PREVIOUSLY THROUGH A CLAIM?
(E.G. WITH YOUR EMPLOYER AND WORKCOVER/ICARE/INSURER)

Yes
No
Back


Confidential, Safe and Secure


DO YOU HAVE A COMCARE CLAIM?

Yes
No
Back


Confidential, Safe and Secure


WHAT TYPE OF INJURIES WERE SUSTAINED BECAUSE OF WORK-RELATED INJURY OR ILLNESS?

CAN SELECT MULTIPLE ANSWERS

Back or neck injury
Hip, knee, ankle injury
Shoulder, elbow, wrist
Amputation
Paraplegia or
Quadriplegia
Psychological illness
or injury
Mesothelioma,
Silicosis or Asthma
Loss of vision
or hearing
Head injury
Injury/illness not listed
Back
Next

Confidential, Safe and Secure


WHAT IS YOUR DATE OF BIRTH?

12345678910111213141516171819202122232425262728293031 Day
JanFebMarAprMayJunJulAugSepOctNovDec Month
2006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925
Year


Back
Next

Confidential, Safe and Secure


FINAL STEP!
PLEASE FILL OUT INFORMATION BELOW SO YOU CAN RECEIVE YOUR RESULTS

First Name
Last Name
Email
Phone
Email

Back


Confidential, Safe and Secure


HOW IT WORKS


3 STEPS TO CLAIMING COMPENSATION BENEFITS


UNCOMPLICATED AND STRESS-FREE


STEP 1
SEE IF YOU QUALIFY



Take the quiz from your phone, tablet or desktop to find out if you are eligible
for compensation benefits from one of our approved partners.


STEP 2
RECEIVE CONSULTATION



You will receive a consultation to assess your application with zero obligations
to proceed.


STEP 3
REVIEW



Compare and review your options easily with the help of a legal specialist.

Check eligibility


FREE ELIGIBLITY CHECK


FIND OUT IN UNDER 60 SECONDS


IF YOU ARE ELIGIBLE FOR COMPENSATION BENEFITS FROM ONE OF OUR APPROVED PARTNERS

To apply you must:

Suffered an injury or illness at work

Injury or Illness occurred within Australia

Injury or Illness occurred less then 3 years ago

Check eligibility


GET STARTED


WHAT ARE YOU WAITING FOR?


DON'T SUFFER IN SILENCE. SEE IF YOU'RE ENTITLED TO COMPENSATION BENEFITS
FOR YOUR INJURY OR ILLNESS

Get Started Now

Claim Mate is a referral service, we refer all enquiries that are initiated on
this website to partners who are licensed to provide their respective products
and/or services and quotes. We receive referral fees and commissions from third
parties companies for making these introductions. Although we cover a wide range
of products and services, we don’t cover every product or service available on
the market. In some cases, we may not have a large selection of partners on
board who can service your specific request. This could be due to your
circumstances that may be unique and only serviceable by a particular provider
or because Claim Mate only has been able to come to an agreement with one
product or service supplier.

By clicking on the “SUBMIT” button, you agree to proceed with a specific product
or service offering through a referral from
https://apply-work-injury.claim-mate.com, you will be dealing directly with the
third party companies and(or) its representatives of that product or service and
no longer with https://apply-work-injury.claim-mate.com / Claim Mate. You
acknowledge and agree to receive notices, phone calls, and any other
communications at the email or telephone number(s) you provided on your
application from the third party companies and(or) its representatives of that
product or service.

The information provided on https://apply-work-injury.claim-mate.com is for
general informational purposes only and is not intended to be a substitute for
professional legal advice. Claim Mate does not guarantee the accuracy of the
information on the website or in any other subsequent communication, including
information provided by contributors or third parties at any particular time. We
strongly advise that you seek advice from a qualified legal professional before
taking any action based on the information provided. Please note that every case
is unique, and the information presented may not be applicable to your
individual circumstances. You must accept sole responsibility associated with
using the material on this website, and the information provided is not a
substitute for legal advice. Therefore, you must not rely on the information
provided on https://apply-work-injury.claim-mate.com or the Claim Mate website
to make any legal decisions regarding your injury or illness.

By submitting your details on this site, you are agreeing to the Terms &
Conditions and have read and understood the Privacy Policy.

© Copyright Claim Mate 2023. All rights reserved.

903/50 Clarence St, Sydney, NSW, 2000

Terms & Conditions | Privacy Policy | Contact

Partner with us