Can the TAC help you?

Telephone 1300 654 329 STD Toll free 1800 332 556 tac.vic.gov.au

ABN 22 033 947 623

The Transport Accident Commission (TAC) pays for the reasonable cost

of treatment and support services for people injured in transport accidents.

You may be eligible to have medical treatment and other services relating

to your accident paid for by the TAC.

Loss of earnings benefits

The TAC can also pay loss of earnings benefits if you are unable to work due to your

accident injuries.

Submitting a TAC claim

While in hospital

By completing the attached form, you are submitting a claim to the TAC for an assessment

of your entitlements.

Once completed, the hospital will send this form to the TAC. The TAC will then contact you

about your entitlements.

After you go home

If you do not complete this form while you are in hospital and would like to lodge a TAC claim,

please telephone the TAC on 1300 654 329.

Personal Details Transport Accident Details

1

PLEASE COMPLETE

Personal details

Residential address Given names

Surname (Family name) Title

Telephone number(s) Primary:

Email address

Date of birth (DD/MM/YYYY) Male

Alternate:

Do you consent to the TAC communicating:

Postal address (If different to residential)

Female

YES NO

YES NO

With you via SMS? With you via Email?

2

PLEASE COMPLETE

Do you require an interpreter?

Language required

If yes, please provide language? YES

NO

The Transport Accident Commission (TAC) pays for the reasonable cost of treatment and support services for people injured in transport accidents. You may be eligible to have your medical treatment and other services relating to your accident paid for by the TAC.

When making decisions about entitlements the TAC follows legislation called the Transport Accident Act 1986

3

PLEASE COMPLETE

Accident details

Accident address

Please describe the accident in your own words Date of accident (DD/MM/YYYY) Accident time

Vehicle registration number?

In what state or territory is the vehicle registered?

AM/PM

What type of vehicle was involved in the transport accident? (Street name, number, town, suburb, state, postcode)

Example: (Car, truck, bus, motorbike, bicycle etc.)

4

PLEASE COMPLETE

Do you believe the accident was the fault of another person

or organisation?

Go to Question 5

If yes, please provide details YES

NO

5

PLEASE COMPLETE

Was it a public transport accident?

Was the transport accident reported to the operator of the vehicle? What is the name of the train, tram, or bus company involved in the transport accident? (e.g. Metro trains, Yarra trams)

YES NO

Go to Question 6

If yes, please provide details YES

NO

6

PLEASE COMPLETE

Did the police attend the scene of the accident?

Police officer’s name?

Date reported to police (DD/MM/YYYY)

At what police station was the report lodged?

Please provide following details (If available) Go to Question 7

YES NO

7

PLEASE COMPLETE

Were you transported from the scene of the accident in an

ambulance?

YES NO

9

PLEASE COMPLETE

Were you taking part in a motor vehicle race, speed trial, rally,

or a test in preparation for one of these events?

YES NO

10

PLEASE COMPLETE

In this accident were you a:

DRIVER CAR PASSENGER TRUCK PASSENGER MOTORCYCLIST PILLION PASSENGER TRAM PASSENGER TRAIN PASSENGER BUS PASSENGER CYCLIST PEDESTRIAN OTHER

Go to Question 12 Go to Question 11 Go to Question 11 Go to Question 12 Go to Question 11 Go to Question 12 Go to Question 12 Go to Question 12 Go to Question 12 Go to Question 11 Go to Question 11

8

PLEASE COMPLETE

Did the accident happen while you were working?

YES NO

Please note, ‘while you were working’ refers to anytime you were: - on duty

- performing activities for your employer - on an authorised break (eg. lunch time), or

Injury Details

11

PLEASE COMPLETE

If you were not the driver of the vehicle, please provide the

details below

Driver’s address Driver’s given names

Driver’s surname (Family name)

Driver’s primary telephone number(s)

13

PLEASE COMPLETE

Were there any other vehicles involved in the transport

accident?

YES NO

12

PLEASE COMPLETE

Were there any witnesses to the accident?

If necessary the TAC may contact you to obtain these details. YES

NO

¹⁵

PLEASE COMPLETE

Prior to your accident, did you have any pre-existing

injuries or conditions?

Go to Question 16

If yes, please provide details YES

NO

14

PLEASE COMPLETE

List the injuries you sustained in the transport accident

Bank Details

Other Details

17

PLEASE COMPLETE

The TAC pays benefits by direct deposit into your bank

account. Please provide details of the account into

which you want your benefits paid.

Account name

BSB number (6 digits)

Account number (up to 10 digits)

Bank name

Branch

Bank address

18

PLEASE COMPLETE

Have you ever made a worker’s compensation or personal

injury claim?

Name of the insurance company/employer Claim number(s)

Number of previous claims

Go to Question 19

If yes, please provide details YES

NO

19

PLEASE COMPLETE

Were there any family members involved in the transport

accident who may also require a claim to be lodged?

Go to Question 20

If yes, please provide details YES

NO

Please list the following information of family members involved. Date of Birth Gender

Name

16

PLEASE COMPLETE

Please provide your general practitioner’s details

Medical practice’s address Medical practice’s name

Doctor or treatment provider’s name

Medical practice’s primary number(s)

Loss of Earnings

The TAC can pay loss of earning benefits if your accident has

affected your ability to work in your usual capacity.

If you apply for loss of earnings benefits, a payment may be

deposited into your nominated bank account. You should

advise your employer that you may have received this

payment to ensure it does not affect any leave entitlements,

such as sick leave.

21

PLEASE COMPLETE

What is your occupation?

‘Occupation’ includes student, pension type, scholarship, home duties and unemployed.

22

PLEASE COMPLETE

Would you like to apply for Loss of Earnings benefits?

Go to Question 27 YES

NO

23

PLEASE COMPLETE

Have you been absent or do you expect to be absent from

work for more than five working days?

What date do you expect to return to work? YES

NO

(DD/MM/YYYY)

24

Please indicate which days of the week you would

usually work?

PLEASE COMPLETE

MON TUE WED THU FRI SAT SUN

Week 1

Week 2

Week 3

Week 4

25

PLEASE COMPLETE

Please provide the name and contact details of the

business/organisation you work for.

Business name

Contact details Contact name

Date commenced employment or business

Australian Business Number (ABN) – Self-Employed Only (DD/MM/YYYY)

Centrelink Disclaimer

If you are currently receiving financial support from Centrelink,

payments of Loss of Earnings by the TAC may affect your

current and ongoing Centrelink Support. The TAC recommends

that you contact Centrelink to discuss with them whether or

not the TAC Loss of Earnings Payments will have an impact on

the support you are receiving.

Tax Implications

Please be aware that by applying for, and receiving Loss of

Earnings from the TAC, you will be receiving a payment which

is recognised as Income by the Australian Taxation Office. The

TAC must deduct withholding tax from your payments of loss

of earnings.

20

PLEASE COMPLETE

What is your employment status?

Employed Self-Employed Unemployed

Not Gainfully Employed *

* Not working and not actively seeking work

26

PLEASE COMPLETE

How much is your gross annual earnings?

$ AUD

‘Gross earnings’ means your earnings before any deductions, including tax.

Alternate Contact Details

General Notes

27

PLEASE COMPLETE

Should someone other than the client involved in the

transport accident be the contact for future

correspondence?

Residential address Given names

Surname (Family name) Title

Contact number(s)

Email address

Date of birth (DD/MM/YYYY) Relationship to client

Postal address (If different to residential) YES

NO

To act as a representative for a client, a signed ‘Authority to release information: client representative form’ must be completed and returned to the TAC.

(This form can be obtained at the TAC website www.tac.vic.gov.au or by calling the TAC contact centre on 1300 654 329)

To finish your application, please proceed to the next page and complete the declaration and authority to release information.

28

PLEASE COMPLETE

This declaration and authority allows the Transport Accident Commission to obtain records or information, which may affect your claim.

I, (insert name)

declare that the information provided in this claim for compensation is true and correct.

I authorise the Transport Accident Commission to contact and obtain information and documents relevant to my transport accident injuries and relevant to any injury or condition that existed before the transport accident and has been affected by the accident from:

- a doctor, ambulance service, hospital or other health service provider; and

- an insurer carrying on the business of providing Worker's

Compensation insurance, personal injury insurance, disability insurance or motor vehicle insurance; and

- the Trustee or Trustees of any superannuation fund; and

- a department, agency or instrumentality of the Commonwealth or the State of Victoria or another State that administers compensation, police, health & social welfare laws and Medicare Australia payments. I further authorise the Transport Accident Commission to contact and obtain information and documents relevant to any financial loss suffered by me as a result of the accident from:

- my employer (or previous employer); and - my accountant.

I consent to each of the persons and bodies mentioned in this authority providing the relevant information and documents to the Transport Accident Commission to assist in the management of my claim for compensation.

This information may be provided to the Transport Accident Commission upon being provided with a clear photocopy or imagery reproduction of this declaration and authority. Important notes accompanying the declaration and authority 1. Section 67(1A) of the Transport Accident Act 1986 provides that

an authority to release information in a claim for compensation has effect and cannot be revoked until a claim is finally determined.

2. It is an offence under Part 8 of the Transport Accident Act 1986 to provide the Transport Accident Commission (TAC) with false or misleading information in an application to attempt to obtain benefits fraudulently.

3. The TAC respects your privacy and is obliged to manage your personal information and health information in accordance with relevant privacy law and the TAC’s privacy policy. The TAC is prevented from divulging information about you unless this is required by law or is required to carry out a function or exercise a power under the Transport Accident Act 1986.

Declaration and authority to release information

4. The TAC will retain the information provided in this claim for compensation and any information obtained using this authority on your claim file. The TAC will use this information to process, assess and manage your claim. The TAC will also use this information to verify your entitlement to benefits under the Transport Accident Act 1986, or to common law damages. If the TAC is unable to collect relevant personal and health information, this may affect the TAC’s ability to assess entitlements to benefits.

5. The TAC may disclose the personal and health information that the TAC has obtained about you where this is required by law or where this is necessary to manage your claim for compensation. Relevant information may be disclosed when necessary to: medical and health service providers; your employer; a

solicitor acting in relation to your claim; other government agencies, such as the Victorian WorkCover Authority; a Court or Tribunal; and a person you authorise to obtain the information.

Signature of claimant

I declare that the claimant appeared to understand the contents of this declaration and authority

Name of witness

Signature of witness

If the claimant is unable to sign this form because of a medical condition Name of person representing the claimant

Signature

Relationship to claimant

(e.g. parent/guardian, administrator or power of attorney) Dated (DD/MM/YYYY)

Dated (DD/MM/YYYY)

Hospital Details Only

Hospital representative

H1

Representative title

Representative name Hospital name

HOSPITAL ONLY

H2

HOSPITAL ONLY

If transported by ambulance (Question 7), please

provide ambulance reference number?

Ambulance reference number

H3

HOSPITAL ONLY

Was the patient admitted?

Date admitted (DD/MM/YYYY)

Date discharged (DD/MM/YYYY) Casualty attendance date (DD/MM/YYYY)

If yes, please provide details YES

NO

Actual Expected

H4

HOSPITAL ONLY

Will the patient require ongoing treatment as a result of

their transport accident injuries?

YES NO

H5

HOSPITAL ONLY

If injury is listed as a head injury (Question 14), please

provide GCS.

Glasgow Coma Score (GCS)

H6

HOSPITAL ONLY

Does the patient have a current medical certificate?

Medical certificate start date (DD/MM/YYYY)

Medical certificate end date (DD/MM/YYYY)

Please attach a copy of medical certificate to scanned claim

form.

If yes, please provide details YES

NO

H7

HOSPITAL ONLY

General Notes