Transport Accident Regulations 1996

i Transport Accident Regulations 1996 S.R. No. 164/1996 TABLE OF PROVISIONS Regulation Page PART 1—PRELIMINARY 1 1. Objectives 1 2. Authorising provision 1 3. Revocation 2 4. Definition 2 PART 2—PRESCRIBED NUMBER OF HOURS 3 5. Prescribed number of hours 3 PART 3—FORMS 4 6. Reference to forms by number 4 7. Statement of earnings form 4 8. Accident report forms 4 9. Notice of unreported accidents 4 10. Claim for compensation form 4 11. Application for review 4 12. Contract of insurance—trailers 5 13. Transitional 5 __________________ SCHEDULE 6 Form 1—Statement of Earnings 6 Form 2—Driver's Accident Report 7 Form 3—Transport Authority Accident Report 9 Form 4—Notice of a Transport Accident 11 Form 5—Claim for Compensation 12 Form 6—Claim for Compensation (Fatal) 15 -- 1 of 21 -- Regulation Page ii Form 7—Notice of Application for Review 17 Form 8—Contract of Insurance 18 ═══════════════ NOTES 19 -- 2 of 21 -- 1 STATUTORY RULES 1996 S.R. No. 164/1996 Transport Accident Act 1986 Transport Accident Regulations 1996 The Governor in Council makes the following Regulations: Dated: 17 December 1996 Responsible Minister: ALAN STOCKDALE Treasurer A. WILTSHIRE Acting Clerk of the Executive Council PART 1—PRELIMINARY 1. Objectives The objectives of these Regulations are— (a) to prescribe forms to be used for the purposes of the Transport Accident Act 1986; (b) to prescribe the number of hours a week for calculating an earner's average weekly earnings for the purposes of the Act; (c) to provide for other matters authorised by the Act. 2. Authorising provision These Regulations are made under section 132 of the Transport Accident Act 1986. -- 3 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 2 3. Revocation (1) The Transport Accident Regulations 19861 are revoked. (2) Part 4 of the Transport Accident (Miscellaneous) Regulations 1994 2 is revoked. 4. Definition In these Regulations "the Act" means the Transport Accident Act 1986. __________________ r. 3 -- 4 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 3 PART 2—PRESCRIBED NUMBER OF HOURS 5. Prescribed number of hours The prescribed number of hours for the purpose of calculating an earner's average weekly earnings under section 4(4)(d) of the Act is 35 hours. __________________ r. 5 -- 5 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 4 PART 3—FORMS 6. Reference to forms by number In this Part 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 of 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. Notice of unreported accidents The prescribed form of notice which may be served on a person under section 65(1) or (2) of the Act is Form 4. 10. Claim for compensation form For the purposes of section 67(1)(a) of the Act— (a) the prescribed form of claim for compensation is Form 5; or (b) if the compensation involves the death of a person in a transport accident, the prescribed form is Form 6. 11. Application for review The prescribed form of application for review under section 77 of the Act is Form 7. r. 6 -- 6 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 5 12. Contract of insurance—trailers The prescribed form of 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 8. 13. Transitional A form that is received by the Commission before 1 July 1997 is in the prescribed form if it complies with the Transport Accident Regulations 19863 as in force immediately before the commencement of these Regulations. __________________ r. 12 -- 7 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 6 SCHEDULE 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 hoursGross 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 __________________ Form 1 -- 8 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 7 Form 2 Regulation 8(1) Driver's Accident Report Form 2 -- 9 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 8 Form 2—continued __________________ Form 2 -- 10 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 9 Form 3 Regulation 8(2) Transport Authority Accident Report Form 3 -- 11 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 10 Form 3—continued __________________ Form 3 -- 12 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 11 Form 4 Regulation 9 NOTICE OF A TRANSPORT ACCIDENT The Transport Accident Commission has been advised of the following details relating to a transport accident: Driver's Name: Address: Registered No.: Date of Accident: The Transport Accident Act 1986 requires drivers of motor vehicles involved in transport accidents to report the details on the enclosed Driver's Accident Report form when, as a result of the accident— • a person is or may have been injured or dies; and • a person may be entitled to claim for compensation. The form must be completed by the driver of the vehicle involved in the accident and must be lodged with the Transport Accident Commission within 28 days of the date of accident or within 14 days of service of this notice, whichever is the later. In the case of a recreation vehicle, if the driver is under 15 years of age, the form is to be completed by the owner, or, if the owner is also under 15 years of age, by the parent or guardian of the owner. A person who does not submit a Driver's Accident Report within the required time is liable to pay a penalty of $50. __________________ Form 4 -- 13 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 12 Form 5 Regulation 10 (a) CLAIM FOR COMPENSATION UNDER THE TRANSPORT ACCIDENT ACT PERSONAL DETAILS of the CLAIMANT Mr Mrs Ms Other INJURY DETAILS Date of death (if applicable) Please describe your transport accident injuries Family name Given names No/Street name Suburb/Town State Home phone Work phone Birth date Male/Female (If Driver or Motorcyclist) Driver Licence No Expiry date Postcode Mobile phone Marital status Were you taken to hospital after the transport accident? If yes, name of hospital Length of stay at hospital...days Are you currently off work due to the transport accident? If yes, number of days off work OCCUPATION DETAILS Complete these details if you wish to claim for loss of earnings Occupation Self employed Employee Name, address and telephone number of employer or own business No/Street name Suburb/Town State Postcode Work phone Mobile phone Have you received social security payments because of the transport accident, or in the 6 months before it? Name of treating doctor Address Please describe your general state of health before the transport accident, including accident and sports injuries and other health problems Please list any WorkCover, WorkCare, public liability or other transport accident claims you have had (including claims since the transport accident) Date of injury Type of claim Did the transport accident happen During your working hours? While you were at work? While you were travelling to or from work? If an interpreter is required, language spoken Arabic Italian Turkish Chinese Macedonian Vietnamese Greek Spanish Other Form 5 -- 14 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 13 FAMILY DETAILS Please provide details of all family members who were in the transport accident with you Full name Address Birth dateRelationship Made claim? Sister/Parent/Spouse/Brother/Child/Other TRANSPORT ACCIDENT DETAILS Accident date Day of the week Accident time Where did the transport accident happen? Street No. and street, Town or Suburb, State, Postcode If travelling in a car or motor cycle, please mark your position What sort of transport user were you? Driver Motorcyclist Car Passenger Pillion Passenger Pedestrian Tram Passenger Bus Passenger Train Passenger Cyclist Other Police Involvement (attended scene/reported to)___________________________police station Name of police officer Please write out how the transport accident happened Were you taking part in, or in a test in preparation for, a motor vehicle race, speed trial, enduro or rally? Please draw a diagram showing how the transport accident happened Were you wearing a seat belt or helmet? Had you consumed any alcohol or drug in the 6 hours before the accident? If travelling in a car, were you thrown out due to the accident? Were you involved in a collision with a fixed object? What was the speed limit at the accident location? Vehicle details Driver Address Phone Registration State of Registration Make Your vehicle Other vehicles STATUTORY DECLARATION I acknowledge that this declaration is true and correct and I make it in the belief that a person making a false declaration is liable to the penalties of perjury. Declared at (place) Before Date Name and address -- 15 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 14 Witness signature Signature of claimant 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 Full name, address and status of person signing the form Full name Address Relationship to injured person Signature __________________ Form 5 Form 5 -- 16 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 15 Form 6 Regulation 10 (b) CLAIM FOR COMPENSATION (FATAL) UNDER THE TRANSPORT ACCIDENT ACT PERSONAL DETAILS OF THE DECEASED Mr Mrs Ms Other INJURY DETAILS Date of death Family name Given names Home address No/Street name Suburb/Town State Date of Birth Male/Female Home phone Language spoken in deceased's family Postcode Marital Status Please describe the deceased's transport accident injuries Name of hospital to which the deceased admitted Did the transport accident happen During the deceased's working hours? While the deceased was at work? Was the deceased travelling to or from work when the transport accident happened? DEPENDENCY DETAILS Complete these details if the deceased person was employed or self-employed Occupation Self-employed Employee Name of employer/own business Address of employer/own business Work phone Please list details of any pre- existing health conditions the deceased may have had before the transport accident. Date of injury Type of Claim Please provide details of spouses and children who were dependent on the deceased Full name Address Birth date Relationship Full time student TRANSPORT ACCIDENT DETAILS Accident date Day of the week Accident time Where did the transport accident happen? Street No. and street, town or suburb, state, postcode Please write out how the transport accident happened If deceased was travelling in a car or motor cycle, please mark the position What sort of transport user was the deceased? Driver Motorcyclist Car Passenger Pillion Passenger Pedestrian Tram Passenger Bus Passenger Train Passenger Cyclist Other Form 6 -- 17 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 16 Was the deceased taking part in, or in a test in preparation for a motor vehicle race, speed trial, enduro or rally? Vehicle details Driver Address Phone Registration State of Registration Make Deceased's vehicle Other vehicles STATUTORY DECLARATION I acknowledge that this declaration is true and correct and I make it in the belief that a person making a false declaration is liable to the penalties of perjury. Declared at (place) Before Date Name and address Witness signature Signature Relationship to the deceased A person authorised under section 107A(1) of the Evidence Act 1958 to witness the signing of a statutory declaration __________________ Form 6 -- 18 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 17 Form 7 Regulation 11 ADMINISTRATIVE APPEALS TRIBUNAL OF VICTORIA NOTICE OF APPLICATION FOR REVIEW UNDER THE TRANSPORT ACCIDENT ACT TO: The Registrar, Administrative Appeals Tribunal PERSONAL DETAILS OF APPLICANT Family name Given names Accident Date Claim No Residential address Birth date Telephone APPLICANT'S SOLICITOR Firm name Address Practitioner Telephone REVIEW List the decision(s) you are seeking to have reviewed Decision Date Explain fully your reasons why the decision(s) should be reviewed 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 __________________ Form 7 -- 19 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 18 Form 8 Regulation 12 CONTRACT OF INSURANCE 1. In consideration of the owner named in the Schedule having paid to the Transport Accident Commission ('the Commission') the premium set out in the Schedule, the Commission agrees subject to and in accordance with the provisions of Part 5 of the Transport Accident Act 1986 to indemnify the owner for the time being of the trailer described in the Schedule or any other person who is at any time in charge of the trailer (whether with or without the authority of the owner for the time being of the trailer) against any liability which may be incurred by that owner or other person in respect of the death or of injury to any person caused by or arising out of the use of the trailer in Victoria or in any other State or in a Territory during the period of insurance set out in the Schedule or during any subsequent period for which the Commission accepts a Renewal Premium. 2. This contract does not extend to indemnify an owner or other person referred to in clause 1 against— (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 unless the liability is one which would have arisen in the absence of such agreement; or (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. 3. If at the time the time of any event giving rise to a liability under this Policy there subsists any other Policy of Insurance or indemnity covering the owner or person in charge in respect of the same liability, the Commission shall not be liable for any more than its rateable proportion. Signed for and on behalf of the Transport Accident Commission Date ═══════════════ Form 8 -- 20 of 21 -- S.R. No. 164/1996 Transport Accident Regulations 1996 19 NOTES 1 S.R. No. 357/1986. Reprinted to S.R. No. 83/1994. 2 S.R. No. 83/1994. 3 See Note 1. Notes -- 21 of 21 --