Transport Accident (Amendment) Regulations 2003
i
Transport Accident (Amendment) Regulations 2003
S.R. No. 31/2003
TABLE OF PROVISIONS
Regulation Page
1. Objective 1
2. Authorising provision 1
3. Commencement 1
4. Amendment to regulation 10 1
5. Forms for general compensation and emergency expenses 2
Form 5—General claim for Compensation under the
Transport Accident Act 1986 2
Form 5A—Emergency Expenses Claim for Compensation
under the Transport Accident Act 1986 12
6. Forms for funeral and dependency benefits claim 15
Form 6—Funeral and Dependency benefits claim for
Compensation under the Transport Accident
Act 1986 15
═══════════════
ENDNOTES 18
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1
STATUTORY RULES 2003
S.R. No. 31/2003
Transport Accident Act 1986
Transport Accident (Amendment) Regulations 2003
The Governor in Council makes the following Regulations:
Dated: 23 April 2003
Responsible Minister:
ROB HULLS
Minister for WorkCover
KATE HASTINGS
Acting Clerk of the Executive Council
1. Objective
The objective of these Regulations is to prescribe
the claim for compensation forms to be used for
the purposes of the Transport Accident Act
1986.
2. Authorising provision
These Regulations are made under section 132 of
the Transport Accident Act 1986.
3. Commencement
These Regulations come into operation on
28 April 2003.
4. Amendment to regulation 10
After regulation 10(a) of the Transport Accident
Regulations 1996 1 insert—
"(aa) if the compensation claim is in relation to
ambulance or casualty expenses, the
prescribed form is Form 5A; or".
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5. Forms for general compensation and emergency
expenses
For Form 5 in the Schedule to the Transport
Accident Regulations 1996 substitute—
'FORM 5
GENERAL CLAIM FOR COMPENSATION UNDER THE
TRANSPORT ACCIDENT ACT 1986
YOUR PERSONAL DETAILS
1. Title
• Surname
• Given names
• Male/Female
• Date of birth
• 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 in the past
5 years, 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. What is the main language you speak at
home?
English
Other (please specify)
TRANSPORT ACCIDENT DETAILS
4. Did police attend the scene of the
accident?
No (go to 5)
Yes—Police Officer's name
Stationed at
5. The accident was reported to the police.
Date reported
Police Officer's name
Stationed at
6. 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.
7. If travelling in a vehicle, what was your
position in the vehicle immediately
before the accident?
8. In this accident were you a—
• Driver (go to 9)
• Car or truck passenger (go to 10)
• Motorcyclist (go to 9)
• Pillion passenger (go to 11)
• Tram Passenger (go to 14)
• Train passenger (go to 14)
• Bus passenger (go to 14)
• Cyclist (go to 15)
• Pedestrian (go to 15)
• Other (go to 15)
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9. Please provide your licence details—
• Licence or permit number
• Expiry date of licence or permit
• Length of time licence or permit has
been held
10. If travelling in a car or truck, were you
thrown out of the vehicle due to the
accident?
Yes
No
11. Were you involved in a collision with a
fixed object?
Yes
No
12. What was the speed limit at the accident
location?
13. Were you the driver of the vehicle?
Yes (go to 14)
If no, provide the following details—
• Driver's surname
• Driver's given names
• Driver's address
• Driver's home phone
• Driver's work phone
• Driver's mobile phone
14. 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?
• 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 15)
No (go to 16)
15. Please provide the following details of
any other vehicle involved in the
accident.
• Other driver's surname
• Other driver's given names
• Other driver's address
• Other driver's home phone
• Other driver's work phone
• Other driver's mobile phone
• Other driver's vehicle registration
number
• Was the vehicle registered in
Victoria?
Yes
No
• If no, in 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)
16. Were you wearing a seatbelt or helmet?
Yes
No
17. Is police action going to be taken in
relation to the accident?
No (go to 18)
Don't know
Yes
If yes, name of person charged
18. Had you consumed any alcohol in the
4 hours before the accident?
No (to 20)
Yes
If yes, type and amount consumed
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19. Was a breath or blood test undertaken?
No (go to 20)
Yes
If yes, what was your reading?
20. Had you consumed any drugs (including
medication) on the day of the accident?
No (go to 21)
Yes
If yes, type and amount consumed
21. Did the accident happen on the way to or
from work?
No
Yes
22. Did the accident happen while you were
working?
No
Yes
23. Were you taking part in a motor vehicle
race, speed trial, enduro or rally or a test
in preparation for one of these events?
No
Yes
24. Were there any witnesses to the accident?
No (go to 25)
If yes, please provide the following
details:
• Witness's surname
• Witness's given names
• Witness's address
• Witness's home phone
• Witness's work phone
• Witness's mobile phone
FAMILY INVOLVEMENT
25. Were any members of your family
injured in the transport accident?
No
Yes
If yes, please provide the following
details:
Family member 1
Full name
Date of birth
Address
Relationship (e.g. spouse)
Has the family member made a claim?
No
Yes
Family member 2
Full name
Date of birth
Address
Relationship (e.g. child)
Has the family member made a claim?
No
Yes
Family member 3
Full name
Date of birth
Address
Relationship (e.g. brother)
Has the family member made a claim?
No
Yes
Family member 4
Full name
Date of birth
Address
Relationship (e.g. parent)
Has the family member made a claim?
No
Yes
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YOUR INJURY DETAILS
26. Please list all your injuries from the
transport accident.
27. Were you transported by ambulance from
the scene of the accident?
No
Yes
28. Were you taken to hospital?
No (go to 29)
Yes
If yes, provide the following details—
• Hospital name
• Was it a visit to the casualty
department only?
Yes (go to 29)
No
If no, date admitted
• Have you been discharged from
hospital?
No
Yes
If yes, date discharged
29. Did you sustain an injury to the head?
No
Yes
30. Did you lose consciousness?
No
Don't know
Yes
If yes, for how long? (hours/minutes)
31. Are you still receiving treatment or
expecting to receive treatment for your
transport accident injuries?
No (go to 33)
Yes
If yes, please provide details of the doctor
who is treating your injuries
• Doctor's name
• Doctor's address
• Doctor's telephone number
32. Is this your usual doctor?
Yes
No
If no, please provide your usual doctor's
details—
• Doctor's name
• Doctor's address
• Doctor's telephone number
PREVIOUS INJURIES OR CONDITIONS
33. Before the accident, have you ever
required treatment—
• by a chiropractor or physiotherapist?
• by a psychologist or psychiatrist?
• involving hospitalisation in the last
5 years?
• causing more than 4 weeks off work
for a medical condition?
34. Before the accident, have 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
• Hip, knee or shoulder condition or
pain
• A drug or substance dependency
(please specify)
• Learning difficulties or ADHD
• Arthritis
• Orthopaedic or spinal injury
• Work related injury
• Epilepsy
• Migraine or similar episodic
headache
• Asthma
• Respiratory condition
• Heart condition
• High blood pressure
• Diabetes
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35. Did you answer "yes" to any part of
question 33 or 34?
No (go to 36)
Yes
If yes, please provide details of the injury
or condition and the treatment you were
receiving before the accident.
Injury or Treatment received
Condition (e.g. Physiotherapy
(e.g. bad back) once a week)
Please list all medication you were taking
in relation to the condition or treatment.
36. Before the accident, did you have home
services, gardening, childcare, or personal
care assistance?
No (go to 37)
Yes
If yes, please provide details of the type of
service, number of hours of service
received per week and who provided the
service.
PREVIOUS CLAIMS
37. Have you ever made a Workers
Compensation Claim?
No
Yes
If yes, please provide the following
details—
• Number of previous claims
In relation to your most recent claim,
please provide the following—
• Claim number
• Name of the Insurance
company/employer
• Date of injury or incident
• Injuries sustained
• Settlement date
38. Are you currently receiving WorkCover
or other workers compensation benefits?
No
Yes
39. Have you ever made a personal injury
claim?
No (go to 40)
If yes, please provide the following
details:
• Number of previous claims
In relation to the most recent claim,
please provide the following details—
• Claim number
• Date of injury or incident
• Injuries sustained
• Insurance company or employer
• Settlement date
OCCUPATION DETAILS
40. What was your occupation at the time of
the accident?
41. Have you received or applied for
Centrelink payments because of this
transport accident?
No
Yes
• If yes, what type of Centrelink
benefit?
• Centrelink reference number
42. Are you liable for a HECS debt as a
result of tertiary studies?
43. What was your employment status at the
time of this accident?
• Employed (go to 44)
• Self employed (go to 44)
• Unemployed (go to 68)
• Not gainfully employed (go to 72)
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44. Have you had time off work because of
your transport accident injuries?
No (go to 72)
Yes
• If yes, have you been absent or do
you expect to be absent from work
for more than 5 working days?
No (go to 72)
Yes
• If 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
Yes Date on which you returned
If self-employed (go to 62)
EMPLOYMENT DETAILS
If you are an employee
45. Please provide the following details
regarding your employment—
• Employee number
• Date employment commenced
• Basis of employment (permanent,
temporary, casual or seasonal)
46. Are you employed on a contractual basis
for a fixed period?
No
Yes
If yes, please provide the following
details—
• Date contract commenced
• Date contract expires
47. Are you an apprentice or trainee?
No
Yes
If yes, provide the following details—
• Type of apprenticeship or traineeship
• Date commenced
• Expected completion date
48. Is the nature of your work physical or
non-physical?
Physical
Non-physical
• Please provide details of your daily
work duties
49. Are alternative duties available to you
(e.g. light or modified duties)
50. Please provide details of your working
week—
• Which days do you work?
• Average hours per day
51. Has your employer paid any amounts to
you in respect of your absence from
work?
No
Yes
If yes, please provide the following
details—
• Nature of payment (e.g. sick leave,
annual leave)
• Date paid from
• Date paid to
• Gross amount paid
52. Is your employer continuing to pay your
wage?
No
Yes
If yes, when will payments cease?
53. Would you prefer to receive any TAC
payments to which you are entitled via
your employer?
No
Yes
54. 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)
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55. Is regular overtime a condition of your
employment?
No
Yes
If yes, how much overtime do you work
on average each week?
hours minutes
56. Have you had a permanent change to your
wages (e.g. a pay rise) in the 12 months
before the accident?
No
Yes
If yes, date changed
57. To assist in processing your claim more
quickly, please indicate those documents
you can provide to confirm your wage.
• Pay slips (for a minimum of six pay
periods before the accident)
• Most recent tax return
• Printout of payments from your
employer
• Group certificate
• Other
• None of the above (go to 58)
58. Please provide details of your wages over the 6 pay periods immediately before the
accident
Pay period
ending
Gross
normal
wage
Overtime Shift
allowance
Other
allowance
Allowance
amount
59. Please provide the following details
regarding your employer—
• Business name
• Address
• Phone number
• Nature of business
• Payroll officer's name
• Payroll officer's contact number
• Is the number of employees on the
payroll more than 5?
60. Are you related to your employer?
No
Yes
If yes, how (e.g. employer is aunt)?
61. Does your employer have a person to
assist you to return to work?
If yes, please provide the following
details—
• Contact name
• Phone number
OPTIONAL EMPLOYER'S
ENDORSEMENT
To assist in processing your claim more
quickly, you may ask your employer or
employer's representative to endorse your
answers to questions 45–61.
The claimant has answered questions 45 to 61
and I certify that the answers to those
questions are true and correct.
Employer's signature or stamp—
Name and signature of employer's
representative
(go to 72)
If you are self employed
62. Please provide the following details—
• Type of business
• Business name and address
• Australian Business Number (ABN)
• What is the status of the business
(e.g. sole trader, partnership, trust,
company)?
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63. Estimate the loss suffered by your
business as a result of the accident.
Has the business ceased completely since
the accident?
No
Yes
64. Have you lodged any taxation returns for
the last 3 financial years?
No
Yes
65. Have you employed substitute labour as a
result of the transport accident?
No
Yes
If yes, please provide a separate statement
detailing—
• Name and address of 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.
66. Please provide details of any other income
you earned from personal exertion.
67. Please provide details of your accountant
or the person to contact regarding your
financial records—
• Name
• Address
• Phone number
(go to 72)
If you are unemployed
68. Did your injuries prevent you from
looking for work?
No
Yes
If yes, how long? (weeks).
Are your injuries still preventing you
from looking for work?
69. Did you work during the 2 years before
the accident?
No
Yes
If yes, provide the following details—
• Employer's name
• Date employed from
• Date employed to
70. At the time of the accident had you
received an offer of employment?
No
Yes
If yes, provide the following details—
• Employer's name
• Employer's address
• Employer's phone
• Scheduled employment start date
Have you started this employment?
No
Yes
If no, reason for not starting
If yes, date started
Dependant's details
71. 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 to you (e.g. son or
daughter)
Is the dependant person a full time
student?
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72. 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 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 police, Health Insurance Commission payments or
social welfare laws.
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.
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 this is 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.
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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 unable to sign this form because of a medical condition
Name of person representing the claimant
Signature
Relationship to claimant
Dated
__________________
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FORM 5A
EMERGENCY EXPENSES CLAIM FOR COMPENSATION UNDER
THE TRANSPORT ACCIDENT ACT 1986
YOUR PERSONAL DETAILS
1. Title
• Surname
• Given names
• Male/Female
• Date of birth
• 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 in the past
5 years, please provide details below—
• Previous surname
• Previous given names
POLICE INVOLVEMENT
2. Did police attend the scene of the
accident?
No (go to 3)
Yes—Police Officer's name
Stationed at
3. The accident was reported to the police.
Date reported
Police Officer's name
Stationed at
TRANSPORT ACCIDENT DETAILS
4. 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.
5. Unless you were a cyclist or pedestrian,
please provide details of the vehicle you
were traveling 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?
• 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 6)
No (go to 7)
6. Please provide the following details of
any other vehicle involved in this
accident.
• Other driver's surname
• Other driver's given names
• Other driver's address
• Other driver's home phone
• Other driver's work phone
• Other driver's mobile phone
• Other driver's vehicle registration
number
• Was the vehicle registered in
Victoria?
Yes
No
If no, in what State was the vehicle
registered?
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7. Were you the driver of the vehicle?
Yes (go to 8)
If no, provide the following details—
• Driver's surname
• Driver's given name
• Driver's address
• Driver's home phone number
• Driver's work phone number
• Driver's mobile phone number
8. Did the accident occur 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
9. Were you taking part in a motor vehicle
race, speed trial, enduro or rally or a test
in preparation for one of these events?
Yes
No
FAMILY INVOLVEMENT
10. Were any members of your family
injured in the transport accident?
No
Yes, please provide details below—
Family member 1
Full name
Address
Date of birth
Relationship (e.g. spouse)
Has the family member made a claim?
No
Yes
Family member 2
Full name
Address
Date of birth
Relationship (e.g. parent, brother, child)
Has the family member made a claim?
No
Yes
YOUR INJURY DETAILS
11. Please list all your injuries from the
transport accident.
12. Were you transported by ambulance from
the scene of the accident?
No
Yes
13. Were you taken to hospital?
No
Yes (hospital name)
Was it a visit to the casualty department
only?
Yes
No (Date admitted)
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14. 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 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 police, Health Insurance Commission payments or
social welfare laws.
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.
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 this is 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.
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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 unable to sign this form because of a medical condition
Name of person representing the claimant
Signature
Relationship to claimant
Dated
__________________'.
6. Forms for funeral and dependency benefits claim
For Form 6 in the Schedule to the Transport
Accident Regulations 1996 substitute—
"FORM 6
FUNERAL 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
• Home telephone number
• Language spoken in the family home
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
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3. SPOUSE, PARTNER AND
DEPENDANT CHILDREN DETAILS
Please provide details of the spouse or
partner and the children of the deceased.
Family member 1
• Full name
• Address
• Date of Birth
• Relationship to the deceased
• Is the person a full time student
Yes
No
Family member 2
• Full name
• Address
• Date of Birth
• Relationship to the deceased
• Is the person a full time student
Yes
No
Family member 3
• Full name
• Address
• Date of Birth
• Relationship to the deceased
• Is the person a full time student
Yes
No
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
Please describe the deceased's transport
accident injuries
Name of hospital to which the deceased
admitted
Please list details of any pre-existing
health conditions the deceased may have
had before the transport accident.
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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 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.
4. The TAC may disclose the personal and health information that the TAC has obtained
from you where this is required by law or where this is necessary to manage your claim
for compensation. Relevant information may be disclosed when this is necessary to:
medical and health service providers; a solicitor acting in relation to your 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
__________________".
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ENDNOTES
1 Reg. 4: S.R. No. 164/1996 as amended by S.R. Nos 64/1999 and 106/2000.
Endnotes
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