Transport Accident Regulations 2007

i Transport Accident Regulations 2007 S.R. No. 49/2007 TABLE OF PROVISIONS Regulation Page 1 Objectives 1 2 Authorising provision 1 3 Revocation 1 4 Definition 2 5 Severe Injuries 2 6 Reference to forms by number 3 7 Statement of earnings form 3 8 Accident report forms 3 9 Claim for compensation form 3 10 Form for contract of insurance regarding trailers 4 11 Transitional 4 __________________ SCHEDULE—Forms 5 Form 1—Statement of Earnings by a Loss of Earning Capacity Beneficiary 5 Form 2—Driver's Accident Report 6 Form 3—Transport Authority Accident Report 8 Form 4—General Claim for Compensation under the Transport Accident Act 1986 10 Form 5—Emergency Expenses Claim for Compensation under the Transport Accident Act 1986 19 Form 6—Burial or Cremation and Dependency Benefits Claim for Compensation under the Transport Accident Act 1986 23 Form 7—Contract of Insurance 26 ═══════════════ ENDNOTES 28 -- 1 of 29 -- 1 STATUTORY RULES 2007 S.R. No. 49/2007 Transport Accident Act 1986 Transport Accident Regulations 2007 The Governor in Council makes the following Regulations: Dated: 12 June 2007 Responsible Minister: TIM HOLDING Minister for Finance, WorkCover and the Transport Accident Commission RUTH LEACH Clerk of the Executive Council 1 Objectives The objectives of these Regulations are— (a) to specify certain injuries for the purposes of the definition of a severe injury in the Transport Accident Act 1986; and (b) to prescribe the forms to be used for the purposes of that Act. 2 Authorising provision These Regulations are made under section 132 of the Transport Accident Act 1986. 3 Revocation The following statutory rules are revoked— (a) the Transport Accident Regulations 19961 ; (b) the Transport Accident (Amendment) Regulations 1999 2 ; -- 2 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 2 (c) the Transport Accident (Amendment) Regulations 2000 3 ; (d) The Transport Accident (Amendment) Regulations 2003 4 ; (e) The Transport Accident (Prescribed Severe Injury) Regulations 20035 . 4 Definition In these Regulations, the Act means the Transport Accident Act 1986. 5 Severe Injuries (1) The following injuries are specified for the purposes of the definition of severe injury in section 3(1) of the Act— (a) an injury that results in permanent blindness; (b) burns to not more than 50 percent of the body that cause severe disfigurement and comprise of full-thickness burns— (i) to the head, neck, arms or lower legs; or (ii) that result in severe difficulties in performing mobility, communication and self-care tasks; (c) a brachial plexus injury that results in the loss of the use of a limb. (2) In this regulation, permanent blindness means— (a) a field of vision that is constricted to 10 degrees or less of arc from central fixation in the better eye, irrespective of corrected visual acuity; or (b) a corrected visual acuity of less than 6/60 of the Snellen Scale in both eyes; or r. 4 -- 3 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 3 (c) a combination of visual defects resulting in the same degree of visual loss as referred to in paragraph (a) or (b). 6 Reference to forms by number In these Regulations, a reference to a form by a particular number is a reference to the form of that number in the Schedule. 7 Statement of earnings form The prescribed form for a statement of earnings under sections 49(4), 50(4) and 51(5) of the Act is Form 1. 8 Accident report forms (1) The prescribed form to be used for making a report under section 64(1) or (3) of the Act is Form 2. (2) The prescribed form to be used for making a report under section 64(2) of the Act is Form 3. 9 Claim for compensation form For the purposes of section 67(1)(a) of the Act— (a) subject to paragraphs (b) and (c), the prescribed form for a claim for compensation is Form 4; and (b) in relation to a claim for compensation that relates only to ambulance or casualty expenses, the prescribed form for the claim is Form 5; and (c) in relation to a claim for compensation in respect of the death of a person in a transport accident, the prescribed form for the claim is Form 6. r. 6 -- 4 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 4 10 Form for contract of insurance regarding trailers The prescribed form for a contract of insurance which may be entered into by the Commission with the owner of a trailer under section 86 of the Act is Form 7. 11 Transitional (1) On and from the commencement day, a contract of insurance in the form prescribed by regulation 12 of the Transport Accident Regulations 1996 as in force immediately before the commencement day is taken to be a contract that complies with the form prescribed by regulation 10 of these Regulations. (2) In this regulation, commencement day means the day these Regulations come into operation. __________________ r. 10 -- 5 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 5 SCHEDULE FORMS Regulation 7 FORM 1 STATEMENT OF EARNINGS BY A LOSS OF EARNING CAPACITY BENEFICIARY Name of claimant Address Claim No Statement period Earnings received as an employee Start date Finish date Name and address Weekly hours Gross pay of employer Other earnings Start date Finish date Nature of activity Gross earnings DECLARATION I declare that the information on this form is true and correct to the best of my knowledge and belief. Signed Date of signing __________________ Sch. -- 6 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 6 FORM 2 Regulation 8(1) DRIVER'S ACCIDENT REPORT 1 Details of driver • Surname • Given Names • Mr, Mrs, Ms • Home address • Home telephone number • Work telephone number • Mobile telephone number • Date of birth • Driver's licence number • Expiry date • State of issue • Period held 2 Accident details • Date of accident • Day of the week • Time • Was the driver injured Yes No • Location of the accident • Describe the circumstances of the accident • Draw a diagram of the accident scene, showing the position of all vehicles and any persons injured 3 Details of driver's vehicle • Registration number of the vehicle driven at the time of the accident • State of registration • Vehicle type (car, truck, motor cycle) • Name and address of owner—if not the driver • What was the estimated speed at time of impact • Mark the points of impact on the diagram with an X • Estimate cost of repairs • Level of damage— Level 1—minor damage, cosmetic panel damage Level 2—moderate damage, driveable vehicle Level 3—major damage—car towed Level 4—extensive damage—car likely to be unrepairable • If your vehicle was towed— Name and address of firm or persons who towed vehicle away • Name of panel beater • Name of comprehensive insurer 4 Details of witnesses • Surname • Given Names • Home address • Home telephone number • Work telephone number • Mobile telephone number 5 Details of other occupants in driver's vehicle • Show by number, the position in the vehicle for other occupants on the diagram • Position number • Surname • Given Names • Home address • Home telephone number • Work telephone number • Mobile telephone number • Was this person injured Yes No Sch. -- 7 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 7 6 Details of all other vehicles involved in the accident • Surname • Given Names • Home address • Registration number • Number of persons in vehicle • Level of damage (see question 3 for levels 1 to 4) 7 Details of all other persons involved in the accident (not in a vehicle at the time of the accident) • Surname • Given Names • Home address • Type of road user (e.g. pedestrian, cyclist etc.) • Was this person injured Yes No Declaration by person making this report I hereby declare that the above information is true and correct to the best of my knowledge and belief Signature Date __________________ Sch. -- 8 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 8 FORM 3 Regulation 8(2) TRANSPORT AUTHORITY ACCIDENT REPORT 1 Name of Authority • Returned to 2 Details of Transport Authority/Operator involved • Vehicle types • End • Vehicle identification Numbers • Destinations • Time table 3 Authority/Operator driver details • Surname • Given Names • Employee identification Number • Male/Female 4 Accident details • Date of accident • Day of the week • Time a.m./p.m. • Location of the accident • Description of the accident • Visibility good/bad • Weather wet/dry • Lighting on/off • Draw a diagram of the accident showing the position of all vehicles and any injured person as at time of impact • Name of the MTA Officer or loss assessor if attended at the scene 5 Police details • Did the Police attend the accident scene— No Yes • If yes please provide the following details— Name of the Police Officer who attended at the scene Police Officer's badge number Station where Officer located 6 Details of persons injured in Authority/Operator Vehicle • Surname • Given Names • Residential address • Home telephone number • Work telephone number • Mobile telephone number • Male/Female • Age • Apparent injuries sustained • Taken to hospital by ambulance No Yes If yes, name of hospital Sch. -- 9 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 9 7 Details of other injured persons • Surname • Given Names • Residential address • Home telephone number • Work telephone number • Mobile telephone number • Male/Female • Age • Registration no. if in a vehicle • Type of road user • Apparent injuries sustained • Taken to hospital by ambulance No Yes If yes, name of hospital 8 Details of all other vehicles involved in the accident • Surname • Given Names • Residential address • Home telephone number • Work telephone number • Mobile telephone number • Registration no. • State of registration. • Make and colour of vehicle • Number of passengers in vehicle, excluding the driver Males Females Children • How did the vehicle leave the scene • Description of damage sustained by vehicle 9 Details of witnesses • Surname • Given Names • Residential address • Home telephone number • Work telephone number • Mobile telephone number • Did an authority employee witness the accident? Yes No 10 General remarks Have you any doubt the injury occurred as stated? If so why? Completed by Name Position Signature Date If report is from tourist railway/tram operator • Name of operator • Address • Telephone number __________________ Sch. -- 10 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 10 FORM 4 Regulation 9(a) GENERAL CLAIM FOR COMPENSATION UNDER THE TRANSPORT ACCIDENT ACT 1986 YOUR PERSONAL DETAILS 1 Title • Surname (family name) • Given names • Date of birth • Male/Female • Residential Address • Home telephone number • Work telephone number • Mobile telephone number • Fax number • E-mail address If you have been known by another name, please provide details below— • Previous surname • Previous given names 2 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 in total) • Account number (up to 10 Digits) • Bank name • Branch • Address 3 Do you need an interpreter? No Yes What language do you require? TRANSPORT ACCIDENT DETAILS 4 Did the police attend the scene of the accident? Yes (go to 5) No Please provide the following— • Date reported • Police Officer's name • Stationed at 5 Please provide the following details— • Date of accident • Day of week • Accident time am/pm • Where did the accident happen? • Please describe in your own words how the accident happened. • Please draw a diagram showing how the accident happened. • Do you believe that the accident was caused by the fault of any other person or organisation? No Yes Please provide details 6 In this accident were you a— • Driver (go to 7) • Car passenger (go to 8) • Truck passenger (go to 8) • Motorcyclist (go to 7) • Pillion passenger (go to 9) • Tram Passenger (go to 9) • Train passenger (go to 9) • Bus passenger (go to 9) • Cyclist (go to 10) • Pedestrian (go to 10) • Other (go to 10) Sch. -- 11 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 11 7 Please provide your driver’s licence details— • Licence or permit number (Interstate or overseas residents must attach a photocopy of their licence) (go to 9) 8 As you were not the driver of the vehicle, please provide the following details • Driver's surname (family name) • Driver's given names • Driver's address • Driver's home telephone number • Driver's work telephone number • Driver's mobile telephone number 9 Please provide details of the vehicle you were travelling in— • Vehicle registration number • Make and model of vehicle (e.g. Holden Commodore) • Was the vehicle registered in Victoria? Yes No If no, in what State was the vehicle registered? • If the vehicle was not registered, at what address was the vehicle usually kept? • Are you the owner of the vehicle? Yes No • If you were the driver at the time of the accident, did you have permission to drive the vehicle? Yes No • Name of company if a train, tram or bus was involved (e.g. Connex Trains) • Was any other vehicle involved in the accident? Yes (go to 10) No (go to 11) 10 Please provide the following details of any other vehicle involved in the accident. • Other driver's surname (family name) • Other driver's given names • Other driver's address • Other driver's home telephone number • Other driver's work telephone number • Other driver's mobile telephone number • Other driver's vehicle registration number • Was the vehicle registered in Victoria? Yes No • What State was the vehicle registered? • Make and model of vehicle (e.g. Holden Commodore) • Name of company if a train, tram or bus was involved (e.g. Connex Trains) 11 Were you wearing a seatbelt or helmet? Yes No 12 Had you consumed any alcohol or drugs (including medication) in the 4 hours before the accident? No Yes Was a breath or blood test undertaken? No Yes 13 Did the accident happen while you were working? No Yes 14 Were you taking part in a motor vehicle race, speed trial or rally or a test in preparation for one of these events? No Yes Sch. -- 12 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 12 15 Were there any witnesses to the accident? No (go to 16) Please provide the following details— • Witness's surname (family name) • Witness's given names • Witness's address • Witness's home telephone number Witness's work telephone number • Witness's mobile telephone number • Witness's email FAMILY INVOLVEMENT 16 Were any members of your family injured in the accident? No Yes Please provide the following details— Family member 1 Full name Date of birth Relationship (e.g. spouse) Address Has the family member made a claim? No Yes Family member 2 Full name Date of birth Relationship (e.g. child) Address Has the family member made a claim? No Yes Family member 3 Full name Date of birth Relationship (e.g. brother) Address Has the family member made a claim? No Yes YOUR INJURY DETAILS 17 Please list all your injuries from the transport accident. As a result of the accident did you lose consciousness? No Don't know Yes If yes, for how long? (minutes/hours). 18 Were you transported by ambulance from the scene of the accident? No Yes 19 Were you taken to hospital? No (go to 20) Yes Please provide the following details— • Hospital name • Was it a visit to the casualty department only? If yes, on what date did you attend? (go to 20) No If no, date admitted • Have you been discharged from hospital? No Yes Please provide the following information— Date discharged Your current contact details (if different from details provided in question 1) Sch. -- 13 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 13 20 Are you still receiving treatment or expecting to receive treatment for your accident injuries? No (go to 21) Yes Please provide details of the doctor or other treatment provider (e.g. physiotherapist or chiropractor) who is treating your injuries— • Doctor or treatment provider's name • Doctor or treatment provider's address • Doctor or treatment provider's telephone number • Date you first saw the doctor or treatment provider for your accident injuries. 21 Is this your usual doctor or treatment provider? Yes No If no, please provide your usual doctor's or treatment provider's details— • Doctor's or treatment provider's name • Doctor's or treatment provider's address • Doctor's or treatment provider's telephone number PREVIOUS INJURIES OR CONDITIONS 22 Before the accident, had you ever required treatment— • by a chiropractor or physiotherapist? • by a psychologist or psychiatrist? • involving hospitalisation in the last 5 years? • causing more than four weeks off work for a medical condition? 23 Before the accident, had you ever suffered from any of the following conditions or problems? • Lower back condition or pain • Neck condition or pain • Head injury or neurological condition (including epilepsy) • Hip condition or pain If yes, indicate left or right • Knee condition or pain If yes, indicate left or right • Shoulder condition or pain If yes, indicate left or right • A drug or substance dependency (please specify) • Learning difficulties or ADHD • Arthritis • Orthopaedic or spinal injury • Work related injury • Migraine or similar episodic headache • Respiratory condition (including asthma) • Heart condition • High blood pressure • Diabetes • Psychological or psychiatric condition • Gastrointestinal condition (including ulcers or gastric reflux) 24 Did you answer "yes" to any part of question 22 or 23? No (go to 25) Yes Please provide details of the injury or condition and the treatment you were receiving before the accident. (e.g. bad back, physio, once a week) Please list all the regular medication you were taking prior to the accident. Sch. -- 14 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 14 25 Before the accident, did you have home services, gardening, childcare, respite care, personal care assistance or other community support service (e.g. meals on wheels)? No (go to 26) Yes Please provide details of the type of service, number of hours of per week and who provided the service. PREVIOUS CLAIMS 26 Have you ever made a worker's compensation or personal injury claim? No Yes If yes, please provide the following details— • Number of previous claims • Claim number(s) • Name of the Insurance company/employer OCCUPATION DETAILS 27 What was your occupation at the time of the accident (including student, pension type, home duties, unemployed)? Please provide a short description of your duties. 28 Had you received or applied for Centrelink payments prior to or because of this accident? Yes No 29 Are you liable for a HELP debt as a result of tertiary studies? Yes No 30 Did you have an offer of employment or were you due to commence employment at the time of the accident? No (go to 31) Yes Please provide the following details— • Employer's name • Employer's address • Employer's telephone number • Scheduled employment start date Have you started this employment? Yes Date started No Reason for not starting 31 What was your employment status at the time of this accident? (Please provide supporting documentation.) • Employed Were you a seasonal worker? Yes No Owner/director of a company? Yes No Beneficiary of a trust? Yes No (go to 32) • Unemployed (go to 42) • Not gainfully employed (not working and not looking for work) (go to 44) • Self employed Were you a sole trader? Yes No A partnership? Yes No (go to 39) Sch. -- 15 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 15 EMPLOYMENT DETAILS If you are an employee 32 Please provide the following details regarding your employment. Date commenced Basis of employment (permanent, temporary, casual, seasonal, contractor, apprentice, trainee) 33 Have you had time off work because of your transport accident injuries? No (go to 44) Yes Have you been absent or do you expect to be absent from work for more than 5 working days? No (go to 44) Yes Please provide the days and dates of the first 5 days absence or expected absence Day 1 date Day 2 date Day 3 date Day 4 date Day 5 date Have you returned to work? No Expected date of return (if known) Yes Date on which you returned Has your employer paid any amounts to you in respect of your absence from work? No Yes Please provide the following details— • Nature of payment (e.g. sick leave or annual leave) • Date paid from • Date paid to • Gross amount paid • Is you employer continuing to pay your wage? No Yes If yes, when will payments cease? 34 On the day of the accident, were you on any type of leave from work or were you due to commence leave within 4 weeks after the date of your accident? No Yes If yes, please specify the type of leave (e.g. sick leave, annual leave, maternity leave or unpaid leave) 35 Please provide details of your working week— Which days do you work? Income Details 36 Have you had a permanent change to your wages (e.g. a pay rise) in the 12 months before the accident? No Yes 37 Please provide the details of your gross wages over the 12 months preceding the accident. • Gross amount • Date from • Date to 38 Please provide the following details regarding all your employers in the last 12 months— • Business name • Address • Telephone number • Is the number of employees on the payroll more than 5? • Does you employer have a person to assist you to return to work? No Yes Please provide the following details— Contact Name Telephone number Sch. -- 16 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 16 If you are self employed (e.g. sole trader, partnership, trust, company) 39 Please provide the following details— • Type of business • Business name • Business address • Australian Business Number (ABN) • What is the status of the business (e.g. sole trader, partnership, trust, company)? Please provide details of your accountant or the person to contact regarding your financial records— • Name • Address • Telephone number 40 Have you lodged any taxation returns for the last 3 financial years? No Yes Please provide copies of your last 3 income tax returns (including financial and business activity statements) and the corresponding Notice of Assessments. 41 Have you employed substitute labour as a result of the transport accident? No Yes Please provide a separate statement detailing— • Name and address of the person employed • Nature of duties performed • Period of each employment • Gross and net wages paid each week • Method of taxation deductions made (i.e. group tax, withholding tax) • Documentary evidence of payment such as cheque butts, bank statements etc. If you were unemployed 42 Did you work during the two years before the accident? No Yes Please provide the following details— • Employer's name • Employer's address • Employer's telephone number • Date employed from • Date employed to • Documentary evidence of work history such as group certificates and taxation returns 43 Did your injuries prevent you from looking for work? No Yes If yes, how long? (weeks). If yes, list the injuries that prevented you from looking for work Are your injuries still preventing you from looking for work? No Yes If yes, list the injuries that are still preventing you from looking for work. Dependant's details 44 Please provide details of all persons who are wholly or partly dependent on you. A dependant is a person who relies on your income in any way. • Full name • Date of birth • Relationship (e.g. spouse) • Address • Is the dependant person a full time student? Yes No Sch. -- 17 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 17 45 DECLARATION AND AUTHORITY TO RELEASE INFORMATION 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 and 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 employers); 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 or 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. Sch. -- 18 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 18 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 inrelation 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 Dated If the Claimant is a child unable to sign this form because of age or a medical condition Name of person representing the claimant Signature Relationship to claimant (e.g. parent/ guardian, administrator or power of attorney) Dated __________________ Sch. -- 19 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 19 FORM 5 Regulation 9(b) EMERGENCY EXPENSES CLAIM FOR COMPENSATION UNDER THE TRANSPORT ACCIDENT ACT 1986 YOUR PERSONAL DETAILS 1 Title • Surname (family name) • Given names • Date of birth • Male/female • Address • Home telephone number • Work telephone number • Mobile telephone number • Fax number • E-mail address If you have been known by another name or have changed your name, please provide details below— • Previous surname (family name) • Previous given names POLICE INVOLVEMENT 2 Did the police attend the scene of the accident? Yes (go to 3) No Please provide the following details: Date reported to police Police Officer's name Stationed at TRANSPORT ACCIDENT DETAILS 3 Please provide the following details— • Date of accident • Day of week • Accident time am/pm • Where did the accident • happen? • Please describe in your own words how the accident happened. 4 Unless you were a cyclist or pedestrian, please provide details of the vehicle you were travelling in— • Vehicle registration number • Make and model of vehicle (e.g. Holden Commodore) • Was the vehicle registered in Victoria? Yes No • If no, in what State was the vehicle registered? • If the vehicle was not registered, at what address was the vehicle usually kept? • Are you the owner of the vehicle? Yes No • Name of company if a train, tram or bus was involved (e.g. Connex Trains) • Was any other vehicle involved in this accident? Yes (go to 5) No (go to 6) Sch. -- 20 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 20 5 Please provide the following details of any other vehicle involved in this accident. • Other driver's surname (family name) • Other driver's given names • Other driver's address • Other driver's home telephone number • Other driver's work telephone number • Other driver's mobile telephone number • Other driver's vehicle registration number • Was the vehicle registered in Victoria? Yes No • What State was the vehicle registered? 6 Were you the driver of the vehicle? Yes (go to 7) No Please provide the following details— • Driver's surname (family name) • Driver's given name • Driver's address • Driver's home telephone number • Driver's work telephone number • Driver's mobile telephone number 7 Did the accident happen while you were working? Yes No Please note, "while you were working" refers to anytime you were— • On duty; or • On an authorised break, (e.g. Lunchtime); or • Performing activities for your employer 8 Were you taking part in a motor vehicle race, speed trial, rally or a test in preparation for one of these events? Yes No FAMILY INVOLVEMENT 9 Were any members of your family injured in the transport accident? No Yes, Please provide details below— Family member 1 Full name Date of birth Relationship (e.g. spouse) Address Has the family member made a claim? No Yes Family member 2 Full name Date of birth Relationship (e.g. child) Address Has the family member made a claim? No Yes YOUR INJURY DETAILS 10 Please list all your injuries from the transport accident. As a result of the accident did you loose consciousness? No Don't know If yes, for how long? (minutes/hours) 11 Were you transported by ambulance from the scene of the accident? No Yes 12 Were you taken to hospital? No Yes • Hospital name • Was it a visit to the casualty department only? Yes No Date admitted Sch. -- 21 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 21 13 DECLARATION AND AUTHORITY TO RELEASE INFORMATION This declaration and authority allows the Transport Accident Commission to obtain information and documents relevant to your claim for compensation if you later decide to claim benefits in addition to ambulance and casualty expenses. 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 and 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 or 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. Sch. -- 22 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 22 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 Dated If the Claimant is a child or 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 __________________ Sch. -- 23 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 23 FORM 6 Regulation 9(c) BURIAL OR CREMATION AND DEPENDENCY BENEFITS CLAIM FOR COMPENSATION UNDER THE TRANSPORT ACCIDENT ACT 1986 1 PERSONAL DETAILS OF THE DECEASED • Title • Surname • Given names • Address • Date of birth • Male/Female • Marital status 2 OCCUPATION DETAILS What was the deceased's occupation at the time of the accident (including student, pension type, home duties, unemployed)? Employed Self employed • Name of employer/own business • Address of employer/own business • Work telephone number 3 SPOUSE, PARTNER AND CHILDREN DETAILS Please provide details of the spouse or partner and the children of the deceased. Family member 1 • Full name • Address • Telephone number • Date of Birth • Relationship to the deceased • Is the person a full time student Yes No Family member 2 • Full name • Address • Telephone number • Date of Birth • Relationship to the deceased • Is the person a full time student Yes No Family member 3 • Full name • Address • Telephone number • Date of Birth • Relationship to the deceased • Is the person a full time student Yes No • Do you or a family member need an interpreter? No Yes If yes, what language do you require? Sch. -- 24 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 24 4 TRANSPORT ACCIDENT DETAILS Accident date Day of the week Accident time Where did the transport accident happen? At the time of the accident, what type of transport user was the deceased? • Driver • Car or truck passenger • Motorcyclist • Pillion passenger • Tram Passenger • Train passenger • Bus passenger • Cyclist • Pedestrian • Other Please provide details of all vehicles involved in the accident Deceased's vehicle (if relevant) • Name of driver • Registration number of the vehicle • State of Registration (e.g. Vic) • Make and model of vehicle Other vehicle • Name of driver • Registration number of the vehicle • State of Registration (e.g. Vic) • Make and model of vehicle Did the accident happen while the deceased was on the way to or from work? Did the accident happen while the deceased was performing his or her daily work duties? Was the deceased taking part in a motor vehicle race, speed trial, enduro or rally or a test in preparation for one of these events? 5 INJURY DETAILS • Date of death • Name of hospital to which the deceased was admitted • Please list details of any pre-existing health conditions the deceased may have had before the transport accident. Important notes accompanying the declaration 1 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 or to attempt to obtain benefits fraudulently. 2 The TAC respects privacy and is obliged to manage 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. 3 The TAC will retain the information provided in this claim for compensation and any other information obtained on your claim file. The TAC will use this information to process, assess and manage the claim. The TAC will also use this information to verify any 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. Sch. -- 25 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 25 4 The TAC may disclose the personal and health information that the TAC has obtained where this is required by law or where this is necessary to manage the claim for compensation. Relevant information may be disclosed when necessary to: medical and health service providers; a solicitor acting in relation to the claim; other government agencies; or a Court or Tribunal. DECLARATION I (insert name) declare that the information provided in this claim for compensation is true and correct. Name of person completing the claim Relationship to the deceased Signature I declare that the person completing the claim appeared to understand the contents of this declaration. Name of witness Signature of witness Dated __________________ Sch. -- 26 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 26 FORM 7 Regulation 10 CONTRACT OF INSURANCE 1 Interpretation In this Contract— Commission means the Transport Accident Commission established under Part 2 of the Transport Accident Act 1986; owner means the person named in the Schedule as the owner of the trailer; premium means the premium set out in the Schedule; Schedule means the Schedule to this Contract; trailer means the trailer described in the Schedule. 2 Indemnity (1) In consideration of the owner having paid to the Commission the premium, the Commission agrees to indemnify— (a) the owner; and (b) any other person who is at any time in charge of the trailer, with or without the authority of the owner— against any liability which may be incurred by the owner, or that other person, in respect of the death of, or injury to, any person caused by, or arising out of, the use in Australia of the trailer. (2) The indemnity set out in this clause applies— (a) subject to Part 5 of the Transport Accident Act 1986; and (b) during— (i) the period of insurance set out in the Schedule; and (ii) any subsequent period for which the Commission accepts a Renewal Premium. Sch. -- 27 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 27 3 Limitation of liability (1) This Contract does not indemnify the owner or the person referred to in clause 2(1)(b) against any of the following— (a) liability to pay compensation under the Accident Compensation Act 1985 or an Act or law referred to in section 37 of the Transport Accident Act 1986; (b) any liability arising under an agreement (other than this Contract) unless the liability would have arisen even in the absence of the agreement; (c) liability in respect of death or injury caused by, or arising out, of the use of the trailer in any period during which the trailer is not registered in Victoria under the Interstate Road Transport Act 1985 of the Commonwealth. (2) If, at the time of any event giving rise to a liability under this Contract, there subsists another contract of insurance or indemnity covering the owner in respect of the same liability, the Commission is not liable under this Contract for any more than its rateable proportion. Signed for and on behalf of the Transport Accident Commission Date ═══════════════ Sch. -- 28 of 29 -- S.R. No. 49/2007 Transport Accident Regulations 2007 28 ENDNOTES 1 Reg. 3(a): S.R. No. 164/1996. 2 Reg. 3(b): S.R. No. 64/1999. 3 Reg. 3(c): S.R. No. 106/2000. 4 Reg. 3(d): S.R. No. 31/2003. 5 Reg. 3(e): S.R. No. 156/2003. Endnotes -- 29 of 29 --