Workers Compensation TIme Sheet - Claim for Payment (NT)

Please use for Northern Territory Claims Only. Timesheets must be completed for claimants who are either not working their normal hours or performing pre-injury duties to enable the correct calculation of worker's compensation entitlements. Timesheets need to be completed inline with NT Government pay fortnights, so if you start back to work on the Monday before payday, you would start recording your hours from the second Monday on the timesheet. Please remember to mark in your lunch breaks. The timesheet should not be completed or forwarded until the hours are actually worked.
  • Please note that in emailing this form to Gallagher Bassett from your designated email account, you declare that you have paid for this service and that the details of this form are true and correct and are related to your compensable disability. If insufficient evidence is received, we will not pay until relevant information is provided.
  • DateHours Worked FromToLunch BreakNo. of Hours Worked Per Day 
  • Drop files here or