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
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.
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?