Transport Accident (Amendment) Regulations 2000

i Transport Accident (Amendment) Regulations 2000 S.R. No. 106/2000 TABLE OF PROVISIONS Regulation Page 1. Objective 1 2. Authorising provision 1 3. Principal Regulations 1 4. Claim for compensation form 1 ═══════════════ ENDNOTES 9 -- 1 of 10 -- 1 STATUTORY RULES 2000 S.R. No. 106/2000 Transport Accident Act 1986 Transport Accident (Amendment) Regulations 2000 The Governor in Council makes the following Regulations: Dated: 17 October 2000 Responsible Minister: BOB CAMERON Minister for WorkCover HELEN DOYE Clerk of the Executive Council 1. Objective The objective of these Regulations is to prescribe the claim for compensation form 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. Principal Regulations In these Regulations the Transport Accident Regulations 1996 1 are called the Principal Regulations. 4. Claim for compensation form For Form 5 in the Schedule to the Principal Regulations substitute— -- 2 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 2 'FORM 5 CLAIM FOR COMPENSATION UNDER THE TRANSPORT ACCIDENT ACT 1986 PERSONAL DETAILS 1. Surname Title Given names Male/Female Date of Birth E-Mail Address (if applicable) Home phone Address Work phone Mobile phone (if applicable) Fax number (if applicable) If you have been known by another name or have changed your name in the past 5 years, please provide details below— Surname Given names 2. Were any members of your family involved in this transport accident? No (go to 3) If yes, please provide details below— Full Name Address Date of Birth Relationship e.g. sister, parent, spouse, brother, child, other Have they made a claim? 3. Do you need an interpreter? No (go to 4) Yes—Language spoken 4. Have you received or applied for Social Security or Centrelink payments— !! because of this transport accident? !! in the six months before this accident? If yes, what type of benefit? Centrelink/Social Security Reference No. 5. The TAC pays benefits by direct deposit into a bank account of your choice. Please provide details of the account into which you want your benefits paid. !! Name in which the account is held !! BSB number (6 digits in total) !! Account number (up to 10 digits) !! Bank name !! Branch !! Address TRANSPORT ACCIDENT DETAILS 6. Did Police attend the scene of the accident? No (go to 7) Yes—Police Officer's Name Stationed at 7. I reported the accident to the Police on (date) to (Police Officer's name), stationed at (name of Police Station) Station book number 8. Provide the following details— !! Date of accident !! Day of week !! Accident time am/pm !! Where did this accident happen? !! Please describe in your own words how this accident happened !! Please draw a diagram showing how this accident happened r. 4 -- 3 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 3 9. In this accident, were you a— !! Driver (go to 10) !! Car or truck passenger (go to 10) !! Motorcyclist (go to 10) !! Pillion passenger (go to 10) !! Tram passenger (go to 15) !! Train passenger (go to 15) !! Bus passenger (go to 15) !! Cyclist (go to 18) !! Pedestrian (go to 19) !! Other (go to 18) 10. What was your position in the vehicle immediately before this accident? 11. If travelling in a car, were you thrown out of the vehicle due to this accident? 12. Were you involved in a collision with a fixed object? 13. What was the speed limit at the accident location? 14. Were you the driver of the vehicle? Yes (go to 15) If no, provide the following details— !! Driver's surname !! Driver's given names !! Driver's address !! Home phone !! Work phone !! Mobile phone 15. Provide details of the vehicle you were travelling in— !! Vehicle registration number !! Was the vehicle registered in Victoria: If no, what State was the vehicle registered in? !! Are you the owner of the vehicle? !! Make and model of vehicle (e.g. Holden Gemini) !! Name of company if train/tram involved (All passengers go to 18) 16. Were you the owner of the vehicle you were driving? Yes (go 17) If no, did you have permission to use the vehicle? 17. Please provide your licence details— !! Licence or permit number !! Expiry date of licence or permit !! Length of time licence or permit has been held 18. Were you wearing a seatbelt or helmet? 19. Is Police action going to be taken in relation to the accident? No (go to 20) If yes, name of person charged 20. Had you consumed any alcohol in the two hours before this accident? No (to 21) If yes, type and amount consumed 21. Was a breath or blood test undertaken? No (go to 22) If yes, what was your reading? 22. Had you consumed any drugs (including medication) in the two hours before this accident? No (go to 23) If yes, type and amount consumed 23. Did this accident happen on the way to or from work? 24. Did this accident happen in the course of your employment? 25. Were you taking part in, or in a test in preparation for, a motor vehicle race or speed trial? -- 4 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 4 26. Was any other vehicle involved in the accident? No (go to 27) If yes, provide the following details— !! Other driver's surname !! Other driver's given names !! Other driver's address !! Home phone !! Work phone !! Mobile phone !! Registration number !! Was the vehicle registered in Victoria? If no, what State was the vehicle registered in? !! Make and model of vehicle (e.g. Holden Gemini) !! Name of company if train/tram involved (e.g. Bayside Trains) 27. Were there any witnesses to this accident? No (go to 28) If yes, please provide details— !! Witness's surname !! Witness's given names !! Witness's address !! Home phone !! Work phone !! Mobile phone 28. Were you transported by ambulance from the scene of this accident? 29. Were you taken to hospital? No (go to 30) If yes, provide details below— !! Hospital Name !! Was it a visit to the casualty Department only? !! Date admitted !! Have you been discharged from hospital? If yes, date discharged 30. List all your injuries from this transport accident. 31. Did you sustain an injury to the head? 32. Did you lose consciousness? No (go to 33) 33. Are you still receiving or expect to receive treatment for your transport accident injuries? No (go to 35) If yes, please provide details of the doctor who is treating your injuries— !! Doctor's name !! Doctor's address !! Doctor's telephone number 34. Is this your usual doctor? Yes (go to 35) If no, please provide your usual doctor's details— !! Doctor's name !! Doctor's address !! Doctor's telephone number 35. Has this transport accident affected any injury or condition you had before the accident? No (go to 36) If yes, please provide details of the injury or condition and the treatment and medication you were taking before the accident 36. Before this accident, have you ever required treatment— !! by a chiropractor or physiotherapist? !! by a psychologist or psychiatrist? !! involving orthopaedic or spinal surgery? !! involving hospitalisation in the last 5 years? !! causing more than 4 weeks off work for a medical condition? 37. Before this 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 !! Vascular condition !! Psychological or psychiatric treatment or condition !! Hip, knee or shoulder condition or pain r. 4 -- 5 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 5 Don't know (go to 33) If yes, for how long? (hours/minutes) !! Drug dependency (specify drug) !! Developmental or cognitive problems !! Arthritis !! Orthopaedic or spinal injury !! Work related injury !! Epilepsy !! Migraine or similar episodic headache !! Asthma !! Heart condition !! Diabetes 38. Did you answer "yes" to any part of question 36 or 37? No (go to 39) If yes, please provide details of the injury or condition and the treatment and medication you were taking before this accident 39. Before this accident, did you have home service, gardening or child minding assistance? No (go to 40) If yes, type of service and number of hours per week 40. Have you ever had a Workers Compensation Claim? No (go to 41) If yes, provide the following details— !! Number of previous claims In relation to your most recent claim, provide the following details— !! Claim number !! Date of injury or incident !! Injuries sustained !! Insurance company/employer !! Settlement date Are you currently receiving WorkCover or other workers compensation benefits? 41. Have you ever had a Personal Injury Claim? No (go to 42) If yes, provide the following details— !! Number of previous claims In relation to your most recent claim, provide the following details— OCCUPATION OR EMPLOYMENT DETAILS 42. What was your occupation at the time of this accident? Are you an employee or self-employed? 43. Please provide details of all persons who are wholly or partly dependent on you— !! Full name !! Date of birth !! Relationship to you !! Address (if not normally resident with you) !! Is this person a full time student? Unemployed details 44. Did your injuries prevent you from looking for work? No (go to 63) If yes, how long? (weeks). Are your injuries still preventing you from looking for work? 45. Did you work during the two years before this accident? No (go to 46) If yes, provide the following details— !! Employer's name !! Date employed from !! Date employed to 46. At the time of this accident had you received an offer of employment? No (go to 61) If yes, provide the following details— !! Employer's name !! Employer's address !! Employer's phone !! Scheduled employment start date Have you started this employment? If yes, date started If no, reason for not starting r. 4 -- 6 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 6 !! Claim number !! Date of injury or incident !! Injuries sustained !! Insurance company or employer !! Settlement date Employment Details 47. Have you had time off work because of your transport accident injuries? No (go to 63) If yes, have you been absent or do you expect to be absent from work for more than 5 days? No (go to 63) If yes, provide details of the first five days of absence or expected absence. Have you returned to work? If yes, what date did you return? If no, what is your expected date of return (if known)? Self-Employed details 48. 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)? 49. Estimate the loss suffered by the business as a result of this accident Has the business ceased completely since this accident? 50. Have you lodged any taxation returns for the last 3 financial years? 51. Have you employed substitute labour? No (go to 52) 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. 53. Please provide details of your accountant or the person to contact regarding your financial records— !! Name !! Address !! Phone number Employee Details 54. Please provide the following details regarding your employment— !! Employee number !! Date employment commenced !! Basis of employment (permanent, temporary, casual, seasonal) Are you employed on a contractual basis for a set period? If yes, period of contract? Are you an apprentice or trainee? If yes, provide the following details— !! Type of apprenticeship or traineeship !! Date commenced !! Expected completion date Please provide details of your daily work duties Is the nature of the work physical or non- physical? Are alternative duties available to you? (e.g. light, modified)? 55. Please provide details of your working week— !! Which days do you work? !! Average hours per day !! Starting and finishing times 56. Have any amounts been paid to you by your employer in respect of your absence from work? No (go to 57) If yes, please provide the following details— !! Nature of payment (e.g. sick leave, annual leave) r. 4 -- 7 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 7 52. Please provide details of other income derived from personal exertion !! Date paid from !! Date paid to !! Gross amount paid Is your employer continuing to pay you? If yes, when will payment cease? 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 from 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). 57. Is regular overtime a condition of your employment? No (go to 58) If yes, how much overtime do you work on average each week? Hours minutes 58. Please provide details of your weekly wage over the 6-week period immediately before this accident Week ending Gross normal wage Hourly rate of pay Overtime Shift allowance Other allowance Allowance type (ie meal) Tax No. of hours worked No. of days worked 59. Please provide the following details regarding your employer— !! Business name !! Address !! Phone number !! Nature of business !! Is the number of employees on the payroll more than 5? !! Are you related to your employer? If yes, how (e.g. employer is aunt)? 60. Does your employer have a person to assist you to return to work? If yes, please provide the following details— !! Contact name !! Phone number 61. In order to ensure that you are taxed at the appropriate rate, please provide your tax file number 62. Are you liable for a HECS debt as a result of tertiary studies? 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 54 to 60. The claimant has answered questions 54 to 60 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— 63. AUTHORITY TO RELEASE INFORMATION This authority allows the Transport Accident Commission to obtain records or information, which may affect your claim. r. 4 r. 4 -- 8 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 8 I authorise the Transport Accident Commission to contact and obtain information and documents relevant to my transport accident injuries or any injury or condition that existed before the transport accident and has been affected by the transport accident from— !! Any doctor, ambulance service, hospital or other health service provider !! An insurer carrying on the business of providing Worker's Compensation insurance or motor vehicle insurance !! A department, agency or instrumentality of the Commonwealth or the State 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 as a result of the accident from— !! My employer (or previous employer) !! My accountant This information may be provided to the Transport Accident Commission upon being provided with a clear photocopy or imagery reproduction of this authority. STATUTORY DECLARATION I declare that the information provided in this claim for compensation is true and correct, and I make this declaration in the belief that a person making a false declaration is liable to the penalties of perjury. Signature of claimant Declared at (Place of declaration) Before Date Address of person declared before Witness signature A person authorised under section 107A(1) of the Evidence Act 1958 to witness the signing of a statutory declaration. If the person signing the form is not the claimant— Surname Given names Address Relationship to claimant Signature Reason why the claimant cannot sign.'. ═══════════════ r. 4 -- 9 of 10 -- S.R. No. 106/2000 Transport Accident (Amendment) Regulations 2000 9 ENDNOTES 1 Reg. 3: S.R. No. 164/1996 as amended by S.R. No. 64/1999. Endnotes -- 10 of 10 --