Visit the NT WorkSafe worker page for the latest forms and information and FAQs.
Please use the below forms for Northern Territory claims only.
Forms
- Workers' compensation claim Form — online
- NT Medical Certificate of Capacity — online
- Medical & Pharmaceutical Items Reimbursement Form — online
- Workers Compensation Timesheet — Claim for Payment — online
- Travel Reimbursement Form — online / hardcopy
- Bank Account Details — for EFT Payments — online
- Miscellaneous/all other items Reimbursement Form — online
- Remittance Advice Form — online
- Re-open Claim Application — PDF / Word
- Secondary Injury Application Form — PDF / Word
- Timesheet — Word
About GB's services
- Introducing GB — PDF
Information
- Frequently asked questions — online
- Guidelines for settling of journey claims — online
- Workers right to cease or refuse unsafe work — online
- Injured at work — PDF
- After you lodge a claim — PDF
- Returning to work — PDF
- Workers Compensation Claims Management Escalation Process — For Claimants — PDF
- Gentle Bear — PDF
Publications
- Workers guide to workers' compensation — online
Support Services
- Interpreting and Translating Services — web / email / phone 1800 334 944
- Indigenous Support Services — email/phone 1800 334 944
Internal Dispute Resolution Process
Gallagher Bassett's reconsideration process allows an injured worker who is unhappy with a decision made by Gallagher Bassett to apply for an internal review of the decision in question.
The review is conducted by a Technical Specialist who is independent from the original decision-making process within 5 business days from receipt of a request. The reconsideration will take into account all information available to us, including existing information on file related to the decision, along with any additional information accompanying this request. The reconsideration process is optional for injured workers and is a free service.
In order for a decision to be reviewed and reconsidered by Gallagher Bassett we ask that you complete the Reconsideration Request form (found below) and return to us along with any accompanying documents to NTReturntoWork@gbtpa.com.au
Useful Links