Can the TAC help you?

Size: px
Start display at page:

Download "Can the TAC help you?"

Transcription

1 Can the TAC help you? The Transport Accident Commission (TAC) pays for the reasonable cost of treatment and support services for people injured in transport accidents. You may be eligible to have medical treatment and other services relating to your accident paid for by the TAC. Loss of earnings benefits The TAC can also pay loss of earnings benefits if you are unable to work due to your accident injuries. Submitting a TAC claim While in hospital By completing the attached form, you are submitting a claim to the TAC for an assessment of your entitlements. Once completed, the hospital will send this form to the TAC. The TAC will then contact you about your entitlements. After you go home If you do not complete this form while you are in hospital and would like to lodge a TAC claim, please telephone the TAC on Telephone STD Toll free tac.vic.gov.au ABN

2

3 The Transport Accident Commission (TAC) pays for the reasonable cost of treatment and support services for people injured in transport accidents. You may be eligible to have your medical treatment and other services relating to your accident paid for by the TAC. When making decisions about entitlements the TAC follows legislation called the Transport Accident Act 1986 Personal Details Transport Accident Details 1 PLEASE COMPLETE 3 PLEASE COMPLETE Personal details Accident details Title Surname (Family name) Date of accident (DD/MM/YYYY) Accident time AM/PM Given names Accident address (Street name, number, town, suburb, state, postcode) Date of birth (DD/MM/YYYY) Male Female Residential address Please describe the accident in your own words Postal address (If different to residential) Telephone number(s) Primary: Alternate: address Do you consent to the TAC communicating: With you via SMS? With you via ? Vehicle registration number? In what state or territory is the vehicle registered? 2 PLEASE COMPLETE Do you require an interpreter? If yes, please provide language? What type of vehicle was involved in the transport accident? Example: (Car, truck, bus, motorbike, bicycle etc.) Language required

4 4 PLEASE COMPLETE Do you believe the accident was the fault of another person or organisation? 7 PLEASE COMPLETE Were you transported from the scene of the accident in an ambulance? Go to Question 5 8 PLEASE COMPLETE Did the accident happen while you were working? Please note, while you were working refers to anytime you were: - on duty - on an authorised break (eg. lunch time), or - performing activities for your employer 5 PLEASE COMPLETE Was it a public transport accident? Go to Question 6 9 PLEASE COMPLETE What is the name of the train, tram, or bus company involved in the transport accident? (e.g. Metro trains, Yarra trams) Were you taking part in a motor vehicle race, speed trial, rally, or a test in preparation for one of these events? Was the transport accident reported to the operator of the vehicle? 6 PLEASE COMPLETE Did the police attend the scene of the accident? Go to Question 7 Please provide following details (If available) Date reported to police (DD/MM/YYYY) Police officer s name? At what police station was the report lodged? 10 PLEASE COMPLETE In this accident were you a: DRIVER CAR PASSENGER TRUCK PASSENGER MOTORCYCLIST PILLION PASSENGER TRAM PASSENGER TRAIN PASSENGER BUS PASSENGER CYCLIST PEDESTRIAN OTHER Go to Question 11 Go to Question 11 Go to Question 11 Go to Question 11 Go to Question 11

5 11 PLEASE COMPLETE If you were not the driver of the vehicle, please provide the details below Driver s surname (Family name) 14 PLEASE COMPLETE Injury Details List the injuries you sustained in the transport accident Driver s given names Driver s address Driver s primary telephone number(s) 12 PLEASE COMPLETE Were there any witnesses to the accident? 15 PLEASE COMPLETE If necessary the TAC may contact you to obtain these details. Prior to your accident, did you have any pre-existing injuries or conditions? 13 PLEASE COMPLETE Were there any other vehicles involved in the transport accident? Go to Question 16

6 16 PLEASE COMPLETE Please provide your general practitioner s details Doctor or treatment provider s name Medical practice s name Medical practice s address 18 PLEASE COMPLETE Other Details Have you ever made a worker s compensation or personal injury claim? Go to Question 19 Number of previous claims Medical practice s primary number(s) Claim number(s) Bank Details Name of the insurance company/employer 17 PLEASE COMPLETE The TAC pays benefits by direct deposit into your bank account. Please provide details of the account into which you want your benefits paid. Account name 19 PLEASE COMPLETE Were there any family members involved in the transport accident who may also require a claim to be lodged? BSB number (6 digits) Go to Question 20 Account number (up to 10 digits) Please list the following information of family members involved. Bank name Name Gender Date of Birth Branch Bank address

7 Loss of Earnings The TAC can pay loss of earning benefits if your accident has affected your ability to work in your usual capacity. If you apply for loss of earnings benefits, a payment may be deposited into your nominated bank account. You should advise your employer that you may have received this payment to ensure it does not affect any leave entitlements, such as sick leave. Tax Implications Please be aware that by applying for, and receiving Loss of Earnings from the TAC, you will be receiving a payment which is recognised as Income by the Australian Taxation Office. The TAC must deduct withholding tax from your payments of loss of earnings. Centrelink Disclaimer If you are currently receiving financial support from Centrelink, payments of Loss of Earnings by the TAC may affect your current and ongoing Centrelink Support. The TAC recommends that you contact Centrelink to discuss with them whether or not the TAC Loss of Earnings Payments will have an impact on the support you are receiving. 23 PLEASE COMPLETE Have you been absent or do you expect to be absent from work for more than five working days? What date do you expect to return to work? (DD/MM/YYYY) 24 Please indicate which days of the week you would usually work? Week 1 Week 2 PLEASE COMPLETE MON TUE WED THU FRI SAT SUN Week 3 20 PLEASE COMPLETE What is your employment status? Week 4 Employed Self-Employed Unemployed Not Gainfully Employed * * Not working and not actively seeking work 25 PLEASE COMPLETE Please provide the name and contact details of the business/organisation you work for. Business name 21 PLEASE COMPLETE What is your occupation? Contact name Contact details Occupation includes student, pension type, scholarship, home duties and unemployed. 22 PLEASE COMPLETE Date commenced employment or business (DD/MM/YYYY) Would you like to apply for Loss of Earnings benefits? Australian Business Number (ABN) Self-Employed Only Go to Question 27

8 26 PLEASE COMPLETE General Notes How much is your gross annual earnings? $ AUD Gross earnings means your earnings before any deductions, including tax. Alternate Contact Details 27 PLEASE COMPLETE Should someone other than the client involved in the transport accident be the contact for future correspondence? Title Surname (Family name) Given names Date of birth (DD/MM/YYYY) Relationship to client Residential address Postal address (If different to residential) Contact number(s) address To act as a representative for a client, a signed Authority to release information: client representative form must be completed and returned to the TAC. (This form can be obtained at the TAC website or by calling the TAC contact centre on ) To finish your application, please proceed to the next page and complete the declaration and authority to release information.

9 Declaration and authority to release information 28 PLEASE COMPLETE This declaration and authority allows the Transport Accident Commission to obtain records or information, which may affect your claim. I, (insert name) declare that the information provided in this claim for compensation is true and correct. I authorise the Transport Accident Commission to contact and obtain information and documents relevant to my transport accident injuries and relevant to any injury or condition that existed before the transport accident and has been affected by the accident from: - a doctor, ambulance service, hospital or other health service provider; and - an insurer carrying on the business of providing Worker's Compensation insurance, personal injury insurance, disability insurance or motor vehicle insurance; and - the Trustee or Trustees of any superannuation fund; and - a department, agency or instrumentality of the Commonwealth or the State of Victoria or another State that administers compensation, police, health & social welfare laws and Medicare Australia payments. I further authorise the Transport Accident Commission to contact and obtain information and documents relevant to any financial loss suffered by me as a result of the accident from: - my employer (or previous employer); and - my accountant. I consent to each of the persons and bodies mentioned in this authority providing the relevant information and documents to the Transport Accident Commission to assist in the management of my claim for compensation. This information may be provided to the Transport Accident Commission upon being provided with a clear photocopy or imagery reproduction of this declaration and authority. Important notes accompanying the declaration and authority 1. Section 67(1A) of the Transport Accident Act 1986 provides that an authority to release information in a claim for compensation has effect and cannot be revoked until a claim is finally determined. 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 (DD/MM/YYYY) If the claimant is unable to sign this form because of a medical condition Name of person representing the claimant Signature 2. It is an offence under Part 8 of the Transport Accident Act 1986 to provide the Transport Accident Commission (TAC) with false or misleading information in an application to attempt to obtain benefits fraudulently. 3. The TAC respects your privacy and is obliged to manage your personal information and health information in accordance with relevant privacy law and the TAC s privacy policy. The TAC is prevented from divulging information about you unless this is required by law or is required to carry out a function or exercise a power under the Transport Accident Act Relationship to claimant (e.g. parent/guardian, administrator or power of attorney) Dated (DD/MM/YYYY)

10

11 Version 1.5 H1 Hospital representative Hospital name Hospital Details Only H5 If injury is listed as a head injury (Question 14), please provide GCS. Glasgow Coma Score (GCS) Representative title Representative name H2 If transported by ambulance (Question 7), please provide ambulance reference number? Ambulance reference number H6 Does the patient have a current medical certificate? Medical certificate start date (DD/MM/YYYY) Medical certificate end date (DD/MM/YYYY) H3 Please attach a copy of medical certificate to scanned claim form. Was the patient admitted? H7 General Notes Casualty attendance date (DD/MM/YYYY) Date admitted (DD/MM/YYYY) Date discharged (DD/MM/YYYY) Actual Expected H4 Will the patient require ongoing treatment as a result of their transport accident injuries?

Application for Scheduled Benefits

Application for Scheduled Benefits Application for Scheduled Benefits CLAIM FORM B To be completed by, or on behalf of, an injured driver/ passenger/motorcyclist/pillion passenger/pedestrian/cyclist Please also complete Claim Form A Notice

More information

Motor Accident Personal Injury Claim Form

Motor Accident Personal Injury Claim Form Motor Accident Personal Injury Claim Form HAVE YOU BEEN INJURED IN A MOTOR VEHICLE ACCIDENT? If you have been injured in a motor vehicle accident in New South Wales, you may be able to access benefits

More information

Application for Benefits under the Motor Accidents (Compensation) Act

Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for

More information

Application for Benefits under the Motor Accidents (Compensation) Act

Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for

More information

Blue Care Income Protection Claim Form

Blue Care Income Protection Claim Form Blue Care Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields

More information

Motor Accident Notification Form (MANF)

Motor Accident Notification Form (MANF) Motor Accident tification Form (MANF) As prescribed under section 84(2)(a) of the Road Transport (Third-Party Insurance) Act 2008 For Compulsory Third-Party (CTP) Insurance Claims in the Australian Capital

More information

Your People, Protected. Personal Accident and Sickness Cover Claim Form

Your People, Protected. Personal Accident and Sickness Cover Claim Form Your People, Protected Personal Accident and Sickness Cover Claim Form Personal Accident and Sickness Cover/Claim Form 2 Personal Accident and Sickness Cover Claim Form IMPORTANT INFORMATION We act upon

More information

Motor Accident Notification Form

Motor Accident Notification Form Motor Accident tification Form This form is Approved Form AF2014-59, approved on 26 August 2014 by Karen Doran, delegate of the director-general, under section 276 of the Road Transport (Third- Party Insurance)

More information

Application for Compensation

Application for Compensation Application for Compensation This Application for Compensation form for injured workers is an approved form under the Workers Compensation and Rehabilitation Act 2003 (the Act). The general information

More information

Fatality Claim Form. South Australia Compulsory Third Party (CTP)

Fatality Claim Form. South Australia Compulsory Third Party (CTP) South Australia Compulsory Third Party (CTP) Fatality Claim Form This form is to be completed by any person who is claiming compensation as a result of a person s death in a motor vehicle accident (please

More information

1. Injured Persons Position in in Vehicle (PLEASE PRINT NEATLY USING CAPITAL LETTERS)

1. Injured Persons Position in in Vehicle (PLEASE PRINT NEATLY USING CAPITAL LETTERS) Common Law Law Claim Claim Form Form Please answer all all questions and and tick tick boxes boxes where where appropriate. Leaving Leaving a question a question blank blank may may delay delay the processing

More information

Compulsory Third Party Personal Injury Claim Notification

Compulsory Third Party Personal Injury Claim Notification Compulsory Third Party Personal Injury Claim tification To claim damages for personal injuries in a motor vehicle accident, please complete this form in BLOCK LETTERS 2. Do you have a solicitor acting

More information

Journey Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A.

Journey Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A. INSURANCE SOLUTIONS CLAIM FORM Journey Injury EXTF052 Call ATC Claims for assistance on 1800 994 694 1. You complete Section A. 2. Your Medical Practitioner completes Section B. 3. Your Employer completes

More information

1. Personal Statement

1. Personal Statement journey injury claim form WFI Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461, Freecall 1300 651 654 IMPORTANT INFORMATION - Read before completing this form. (The issuing of this form is

More information

Claim for Compensation for a Work-related death

Claim for Compensation for a Work-related death SRC 184 (March 2014) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act)

More information

Wesley Mission Income Protection Claim Form

Wesley Mission Income Protection Claim Form Wesley Mission Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all

More information

THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM.

THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM. CLAIM FORM Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY CLAIM

More information

Combined Insurance Claim Form

Combined Insurance Claim Form Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.

More information

Notice of Accident Claim Form

Notice of Accident Claim Form Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance

More information

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle

CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim

More information

EMPLOYEE INCOME PROTECTION INSURANCE CLAIM FORM

EMPLOYEE INCOME PROTECTION INSURANCE CLAIM FORM Section 1 Claimant Details This form is to be completed in the event of: An insured employee being injured, or An Insured Employee suffering sickness that is covered under the company policy. Please ensure

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM (If there is not enough room on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete.) Please lodge your claim to

More information

Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application

Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application Losing a family member in a motor vehicle accident is a traumatic and difficult experience. The Motor Accidents

More information

GIO Workers Compensation Australian Capital Territory

GIO Workers Compensation Australian Capital Territory GIO Workers Compensation Australian Capital Territory Employee s claim form Employer s policy number: Complete all questions fully and accurately, to ensure accurate decisions can be made about your claim.

More information

Details of Helivac RAC Claim

Details of Helivac RAC Claim Details of Helivac RAC Claim A. Claimant details 1. Title: 2. Surname: 3. Name: 4. Date of birth: 5. ID number / Passport number: Note: A certified legible copy of your identity document must be attached

More information

WageGuard Group Income Protection Claim Form

WageGuard Group Income Protection Claim Form WageGuard Group Income Protection Claim Form Frequently Asked Questions How long will it take to complete my section of the form? We ve tested it -- it takes about 20 minutes. We want to settle your claim

More information

Asbestos-Related Diseases - Claim for Compensation

Asbestos-Related Diseases - Claim for Compensation Asbestos-Related Diseases - Claim for Compensation (Member of the family) Asbestos-Related Diseases (Occupational Exposure) Compensation Act 2011 2 WHO CAN MAKE A CLAIM Certain family members of a person

More information

Beazley Energy Super Income Protection. form. claim

Beazley Energy Super Income Protection. form. claim Beazley Energy Super Income Protection form claim Beazley Energy Super Income Protection Claim form Page 2 claim contents form Privacy statement Page 3 Important notice Page 4 Section A Claimants section

More information

MOTOR VEHICLE CLAIM FORM

MOTOR VEHICLE CLAIM FORM MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

Insurance Transfer Form Russell SuperSolution Master Trust Private Division

Insurance Transfer Form Russell SuperSolution Master Trust Private Division Insurance Transfer Form Russell SuperSolution Master Trust Private Division If you hold insurance cover in another superannuation fund or directly with another life insurer, you can apply to transfer your

More information

Claim Form. Journey Report Form. To be completed by Policyholder

Claim Form. Journey Report Form. To be completed by Policyholder This form must be accompanied by an Attending Physicians Statement, which can be obtained by telephoning any of our offices listed. By furnishing this Form the Company makes no admission of Liability or

More information

AMWU PROTECT INJURY AND SICKNESS

AMWU PROTECT INJURY AND SICKNESS INSURANCE SOLUTIONS CLAIM FORM AMWU Protect Injury EXTF061 For dental claims, please use the AMWU Protect Accidental Dental Injury claim form. Call ATC for assistance on 1800 994 694 1. You complete Section

More information

Contractors Injury and Sickness

Contractors Injury and Sickness INSURANCE SOLUTIONS CLAIM FORM Contractors Injury and Sickness EXTF059 Call ATC Claims for assistance on 1800 994 694 1. You complete Section A, including either the Injury statement OR the Sickness statement.

More information

Sports Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A and B.

Sports Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A and B. INSURANCE SOLUTIONS CLAIM FORM Sports Injury EXTF04820140311 Call ATC Claims for assistance on 1800 994 694 1. You complete Section A and B. 2. If you have a Non Medicare Expense claim, you should also

More information

Notice of Accident Claim Form

Notice of Accident Claim Form Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Non-Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident

More information

FORM 2 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Health Care Claims)

FORM 2 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Health Care Claims) FORM 2 PERSONAL INJURIES PROCEEDINGS ACT 2002 NOTICE OF CLAIM (Health Care Claims) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ATTACHED AS THE LAST THREE PAGES OF THE FORM PLEASE READ INSTRUCTIONS CAREFULLY

More information

Workers Compensation claim form

Workers Compensation claim form Form Workers Compensation claim form STOP - this form is available to be filled in electronically on the NT WorkSafe web site www.worksafe.nt.gov.au. Fill the form in electronically then save a copy to

More information

Early release of super on compassionate grounds How to make a claim

Early release of super on compassionate grounds How to make a claim Early release of super on compassionate grounds How to make a claim Please note if you have ceased work due to sickness or injury, call us on 13 11 84 before proceeding. Am I eligible to make a claim?

More information

Protect Injury and Sickness

Protect Injury and Sickness INSURANCE SOLUTIONS CLAIM FORM Protect Injury and Sickness EXTF058 For dental claims, please use the Protect Accidental Dental Injury claim form. Call ATC for assistance on 1800 994 694 1. You complete

More information

Level 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com.

Level 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com. Level 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com.au Professional Risk Underwriting Pty Ltd ABN 80 103 953 073.

More information

Personal Injury Claim Form

Personal Injury Claim Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia 1800 688 640 claims phone 1800 815 675 customer service +61 (0)2 9231 3697

More information

Sports Injury CLAIM FORM. Call ATC for assistance on 1800 994 694. 1. You complete Section A and B.

Sports Injury CLAIM FORM. Call ATC for assistance on 1800 994 694. 1. You complete Section A and B. INSURANCE SOLUTIONS CLAIM FORM Sports Injury EXTF03520130320 Call ATC for assistance on 1800 994 694 1. You complete Section A and B. 2. If you have a Non Medicare Expense claim, you should also complete

More information

FORM 1 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Non-Health Care Claims)

FORM 1 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Non-Health Care Claims) FORM 1 PERSONAL INJURIES PROCEEDINGS ACT 2002 NOTICE OF CLAIM (Non-Health Care Claims) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ATTACHED AS THE LAST THREE PAGES OF THE FORM PLEASE READ INSTRUCTIONS CAREFULLY

More information

Personal Injury Claim Form

Personal Injury Claim Form Personal Injury Claim Form A.I.D.K.A AUSTRALIAN INDEPENDENT DIRT KART ASSOCIATION POLICY NUMBER 5494580 Correct completion of these forms will assist us to make accurate and faster decisions regarding

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form Motor Vehicle Claim Form MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring

More information

PayCover Income Protection Claim Form

PayCover Income Protection Claim Form PayCover Income Protection Claim Form Frequently Asked Questions How long will it take to complete my section of the form? We ve tested it -- it takes about 20 minutes. We want to settle your claim for

More information

Citibank Travel Insurance Claim Form

Citibank Travel Insurance Claim Form ACE Insurance Limited ABN 23 001 642 020 AFSL. 239687 Level 1, 51 Berry Street rth Sydney NSW 2060 Australia PO Box 403 rth Sydney NSW 2059 Australia 1800 305 422 (02) 8912 9704 (02) 9231 3697 +61 2 8912

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Employer: Claimants Name: Job

More information

I ve been injured at work. What do I do? Information for workers

I ve been injured at work. What do I do? Information for workers The Application for Compensation form is an approved form under the Workers Compensation and Rehabilitation Act 2003. The general information contained on this and the following two pages are not part

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Please return claim form to: Corporate Services Network 2 / 280 George Street Sydney NSW 2000 Ph: +61 2 8256 1770 Fax: +61 2 8256 1775 E-mail: claims@csnet.com.au Employer: Claimants Name: Job Title: Work

More information

UPlus Income Protection Claim Form

UPlus Income Protection Claim Form UPlus Income Protection Claim Form Frequently Asked Questions How long will it take to complete my section of the form? We ve tested it -- it takes about 20 minutes. We want to settle your claim for you

More information

Construct Australia Income Protection Services Injury and Sickness Claim Form

Construct Australia Income Protection Services Injury and Sickness Claim Form 1 of 6 Construct Australia Income Protection Services Injury and Sickness Claim Form This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement Section

More information

NT WORKERS COMPENSATION CLAIM FORM

NT WORKERS COMPENSATION CLAIM FORM Information for Workers Guidance to PART 1 of the Claim Form Notify your employer of your injury, verbally or in writing, as soon as practicable. Fully complete PART 1 (questions 1 to 8) of the following

More information

Australian Trainers Association Group Personal Accident Insurance Claim Form

Australian Trainers Association Group Personal Accident Insurance Claim Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au A&H.claims.australia@ace-ina.com

More information

Travel Insurance Report Form

Travel Insurance Report Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: 0028332 Claim Number: s PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TENPIN BOWLING AUSTRALIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised

More information

CLAIM FOR WORKERS COMPENSATION

CLAIM FOR WORKERS COMPENSATION CLAIM FOR WORKERS COMPENSATION Seafarers Rehabilitation and Compensation Act 1992 Information about claiming workers compensation In this document, all references to the employer mean the employer against

More information

Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying super fund.

Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying super fund. Benefit access Gesb Super and West State Super SUP E R ANNUATION Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying

More information

JUDO FEDERATION OF AUSTRALIA

JUDO FEDERATION OF AUSTRALIA Office use only Policy Number: ANA043293PAD Claim Number: JUDO FEDERATION OF AUSTRALIA PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR : V-Insurance Group Pty Ltd Authorised Representative No. 432898 an

More information

Personal Injury Claim Form

Personal Injury Claim Form ACE Insurance Limited ACE Insurance Limited GPO Box 4065 1800 688 640 claims phone ABN 23 001 642 020 ABN 23 001 642 020 Sydney NSW 2001 1800 815 675 customer service The ACE Building GPO Box 4065 Claims

More information

YACHTING AUSTRALIA SUMMARY OF INSURANCE COVER

YACHTING AUSTRALIA SUMMARY OF INSURANCE COVER YACHTING AUSTRALIA SUMMARY OF INSURANCE COVER Death & Permanent Disablement A lump sum benefit is payable in the event of death or a Permanent Disability. The scale of benefits is defined in the policy.

More information

Claim for Compensation for a Work-related death

Claim for Compensation for a Work-related death SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the

More information

INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM

INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM 1 of 7 INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement The claimant is to complete all

More information

third party claim form RAF 1

third party claim form RAF 1 1 personal details of claimant: Title Surname Postal address / Passport number te: A certified legible copy of your identity document must be attached to this claim form Home telephone number Work telephone

More information

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE You fully complete every question before your doctor completes his statement.

More information

Accident And/Or Sickness Claim Form

Accident And/Or Sickness Claim Form Accident And/Or Sickness Claim Form Please forward this completed form to: Claims Department JUA Underwriting Agency Pty Ltd Locked Bag 11 ROYAL EXCHANGE POST OFFICE NSW 1225 Policy underwritten by certain

More information

Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1.

Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Form Workers compensation claim form Part 1 To be filled in by the worker. The following information is provided as guidance to workers filling in Part 1. Notify your employer of your injury or disease

More information

Travel Insurance Report Form

Travel Insurance Report Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia 1800 688 640 claims phone 1800 815 675 customer service +61 (0)2 9231 3697

More information

PERSONAL ACCIDENT CLAIM FORM - MEMBERS

PERSONAL ACCIDENT CLAIM FORM - MEMBERS Pony Club Insurance Scheme PERSONAL ACCIDENT CLAIM FORM - MEMBERS Please read this page before completing the Claim Form Dear Member Thank you for your Claim Form request. This letter contains important

More information

SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form

SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form Dear Member, Thank you for your Claim Form request. This letter contains important information relevant to your

More information

Application for Bond Loan and Rental Grant assistance

Application for Bond Loan and Rental Grant assistance Office use only (application number) Bond Loan Rental Grant Application for Bond Loan and Rental Grant assistance The Department of Housing and Public Works provides Bond Loans and Rental Grants to people

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Willis Australia Limited ABN 90 000 321 237 AFS 240600 Office use only Policy Number: SUA/003700 Claim Number:. PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR NETBALL VICTORIA Willis Australia Limited

More information

Form 275 Notice of claim for damages

Form 275 Notice of claim for damages Department of Justice and Attorney-General Workers Compensation Regulator Form 275 Notice of claim for damages Version 3 Workers Compensation and Rehabilitation Act 2003 Section 275 This is an approved

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form Motor Vehicle Claim Form Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM ACCIDENT & HEALTH PERSONAL INJURY CLAIM FORM Send claim to: Accident & Health Claims Department ACE Insurance Limited GPO Box 4065 Sydney NSW 2001 Australia Claims phone: 1800 688 640 Customer service:

More information

Notice of Accident Claim Form

Notice of Accident Claim Form Insurer's Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) tice of Accident Claim Form (n-fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance

More information

CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH

CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH Seafarers Rehabilitation and Compensation Act 1992 Information about claiming compensation In this document, all references to the employer mean the employer

More information

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST EQUILAW Solicitors Ph: 02 6542 5566 Market House 4 Market Street Muswellbrook NSW 2333 Fax: 02 6543 4397 info@equilaw.com.au equilaw.com.au MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST Bring this completed

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: AN A038364 PAD Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TRIATHLON AUSTRALIA V-Insurance Group Pty Ltd Level 28, Angel Place, 123 Pitt Street, SYDNEY

More information

First Notice of Claim for Illness or Injury

First Notice of Claim for Illness or Injury First Notice of Claim for Illness or Injury How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: SUA/002202 Claim Number: Willis Australia Limited ABN 90 000 321 237 AFS 240600 PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TRIATHLON AUSTRALIA Willis Australia Limited

More information

MEDICAL PRACTITIONERS SEEKING APPROVAL AS INDEPENDENT MEDICAL EXAMINERS - GENERAL PRACTITIONERS

MEDICAL PRACTITIONERS SEEKING APPROVAL AS INDEPENDENT MEDICAL EXAMINERS - GENERAL PRACTITIONERS MEDICAL PRACTITIONERS SEEKING APPROVAL AS INDEPENDENT MEDICAL EXAMINERS - GENERAL PRACTITIONERS 1. Personal Details What is your medical specialty (if any)? Title: Dr Mr Mrs Ms Other (please specify) Family

More information

YACHTING AUSTRALIA SUMMARY OF INSURANCE COVER

YACHTING AUSTRALIA SUMMARY OF INSURANCE COVER YACHTING AUSTRALIA SUMMARY OF INSURANCE COVER Death & Permanent Disablement A lump sum benefit is payable in the event of death or a Permanent Disability. The scale of benefits is defined in the policy.

More information

Asbestos-Related Diseases - Claim for Compensation

Asbestos-Related Diseases - Claim for Compensation Asbestos-Related Diseases - Claim for Compensation (Worker) Asbestos-Related Diseases (Occupational Exposure) Compensation Act 2011 1 WHO CAN MAKE A CLAIM 1. Person with an asbestos-related disease You

More information

Travel Insurance Report Form

Travel Insurance Report Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815

More information

PETANQUE FEDERATION AUSTRALIA LTD

PETANQUE FEDERATION AUSTRALIA LTD Willis Australia Limited ABN: 90 000 321 237 AFS License Number 240600 Office use only Claim Number:. PETANQUE FEDERATION AUSTRALIA LTD PERSONAL INJURY CLAIM FORM Willis Australia Limited HEAD OFFICE Level

More information

CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES

CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES Correct completion of these forms will assist us to make accurate and faster decisions

More information

PERSONAL INJURY INSURANCE CLAIM FORM FOR

PERSONAL INJURY INSURANCE CLAIM FORM FOR PERSONAL INJURY INSURANCE CLAIM FORM FOR Please ensure all sections are fully completed prior to submitting your claim. Failure to complete all sections of this form may delay settlement of your claim.

More information

Second owner. Postal address. Email address. a) Are you notifying a change of address? Y N

Second owner. Postal address. Email address. a) Are you notifying a change of address? Y N Claim Form Medical Private Medical Cover Policy number 1.0 Life assured s details Title Surname First name(s) Male Female of birth Street address Suburb Town/city Postcode Postal address (if different

More information

1. Claimant Details. personal accident and sickness claim form

1. Claimant Details. personal accident and sickness claim form personal accident and sickness claim form Wesfarmers General Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461 Level 2, 99 Melbourne Street, South Brisbane, QLD 4101 or GPO Box 524 Brisbane,

More information

Form Workers compensation claim form

Form Workers compensation claim form Form Workers compensation claim form Part 1 of the claim form is to be filled in by the worker. The following information is provided as guidance to workers filling in Part 1 Notify your employer of your

More information

Income protection claims

Income protection claims PSSap14 04/12 Income protection claims Who should read this? Members with income protection cover who have not worked for an extended period of time due to injury or sickness and wish to claim for income

More information

Compensation and damages

Compensation and damages tes for Compensation and damages Purpose of this form Definition of a partner What you must tell us Are you receiving or about to receive compensation? This form is part of your claim for payment and is

More information

PERSONAL ACCIDENT CLAIM FORM

PERSONAL ACCIDENT CLAIM FORM PERSONAL ACCIDENT CLAIM FORM Use this form when: A worker has suffered an accident, outside working hours and wishes to claim weekly benefits. This form should be completed as soon as it appears you will

More information

Motor Vehicle Claim Form

Motor Vehicle Claim Form SSAA Insurance Brokers Pty Ltd Phone (08) 8332 0281 The Precinct Freecall 1800 808 608 Suite 14, 539 Greenhill Road Facsimile (08) 8332 0303 539 Greenhill Road Email insurance@ssaains.com.au Hazelwood

More information

Advance Retirement Suite Super Early Release Financial Hardship Application

Advance Retirement Suite Super Early Release Financial Hardship Application Advance Retirement Suite Super Early Release Financial Hardship Application Trustee: BT Funds Management Ltd (BTFM) ABN 63 002 916 458 AFSL 233724 GUIDE TO COMPLETING THIS FORM > > Use this form if you

More information