Personal Injury Forms (NSW)

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1 Personal Injury Forms (NSW) Form Name Form No. Precedent Code Authorities for Information Authority to Receive Deeds Authority to Receive Hospital Records Authority to Receive Medical Report Authority to Receive Taxation Records Authority to Release File Letter to Hospital requesting copy records Request for Information - NSW Ambulance Service Request for Information - RTA - Solicitors Declaration Request for Information - RTA Request under the FOI Act - Centrelink Request under the FOI Act - Hospital Request under the FOI Act Authorities for Information >> Medicare and Centrelink Compensation Forms Centrelink - Estimate of Charge Letter to client regarding HIC Letter to HIC enclosing request for Notice of Past Benefits Letter to Medicare Australia Requesting Notice of Past Benefits Medicare Australia - Authority to release information Medicare Australia - Compensation payer's electronic funds transfer (EFT) details collection Medicare Australia - Compensation Recovery Electronic Funds Transfer (EFT) Details Collection Medicare Australia - Notice of Judgment or Settlement Medicare Australia - Notice of Reimbursement Arrangement Medicare Australia - Request for a Notice of Past Benefits Medicare Australia - Request for Medicare History Statement Medicare Australia - Section 23A statement and Statutory Declaration Authorities for Information >> Police Forms Application for bail report criminal record check in NSW only Application for incident report Request for non-personal information Request for personal information Coal Miner Compensation Forms Application for Medical Panel Certificate of Compliance Statement of Claim - Bush Fire - Emergency and Rescue Services - DDT LL-NSW-PI-0161 LL-NSW-PI-0124 LL-NSW-PI-0125 LL-NSW-PI-0126 LL-NSW-PI-0131 LL-NSW-PI-0163 LL-NSW-PI-0127 LL-NSW-PI-0152 LL-NSW-PI-0151 LL-NSW-PI-0129 LL-NSW-PI-0130 LL-NSW-PI-0128 LL-NSW-PI-0138 LL-NSW-PI-0137 LL-NSW-PI-0136 LL-NSW-PI-0139 LL-NSW-PI-0135 LL-NSW-PI-0177 LL-NSW-PI-0178 LL-NSW-PI-0132 LL-NSW-PI-0134 LL-NSW-PI-0133 LL-NSW-PI-0165 LL-NSW-PI-0166 LL-NSW-PI-0143 LL-NSW-PI-0140 LL-NSW-PI-0142 LL-NSW-PI-0141 LL-NSW-PI-0109 LL-NSW-PI-0110 LL-NSW-PI-0107 Personal Injury Forms (NSW) 1-2 users 3-8 users 9+ users No. of forms 172 Purchase price (ex GST) $55.00 $82.50 $ This list is current as at 31 October 2008 Monthly subscription fee (ex GST) $3.60 $5.90 $8.60 Smokeball Page 1 of 6

2 and Sport Injuries Statement of Claim - Coal Miners Compensation List LL-NSW-PI-0105 Statement of Claim - Coal Miners Compensation Redemption LL-NSW-PI-0108 Statement of Claim - Deceased Worker - Coal Miners Compensation List LL-NSW-PI-0106 Document and Information Schedules Callover LL-NSW-PI-0145 Chronology form LL-NSW-PI-0153 Court Mention Sheet LL-NSW-PI-0164 Hearing LL-NSW-PI-0147 Medical Expenses and Treatment LL-NSW-PI-0149 Mention LL-NSW-PI-0144 Privilege LL-NSW-PI-0146 Schedule of Medical Reports LL-NSW-PI-0148 Schedule of Witnesses LL-NSW-PI-0150 Dust Diseases Tribunal Forms Advice to practitioners - No 4 of 2005 LL-NSW-PI-0069 Defendants Reply Form 2 LL-NSW-PI-0068 Plaintiffs Statement of Particulars Form 1 LL-NSW-PI-0067 Industrial Deafness Correspondence >> Client Letter to client advising of referral to medical panel LL-NSW-PI-0090 Letter to client advising unable to commence claim - less than 6 percent LL-NSW-PI-0091 Letter to client confirming settlement LL-NSW-PI-0092 Letter to client enclosing settlement monies LL-NSW-PI-0093 Letter to client regarding referral for CT scan LL-NSW-PI-0095 Letter to client seeking instructions to make claim LL-NSW-PI-0096 Letter to client to advise of medical appointment LL-NSW-PI-0097 Letter to client to answer questionnaire LL-NSW-PI-0098 Industrial Deafness Correspondence >> Doctor Letter to doctor to perform audiogram LL-NSW-PI-0094 Letter to qualifying doctor requesting medico-legal report LL-NSW-PI-0099 Industrial Deafness Court Forms Application for Examination by a Medical Panel - Boilermakers Deafness LL-NSW-PI-0089 Motor Accident Forms Offer of Compromise Pursuant to Part 19A LL-NSW-PI-0159 Motor Accident Forms >> MAA - Claim Forms Accident Notification Form LL-NSW-PI-0123 Certificate of Earnings LL-NSW-PI-0122 Motor Accident Personal Injury Claim Form LL-NSW-PI-0121 Motor Accident Forms >> MAA - Claim Forms >> Claim forms for accidents prior to 1 October 2008 Accident Notification Form LL-NSW-PI-0188 Certificate of Earnings LL-NSW-PI-0187 Motor Accident Personal Injury Claim Form LL-NSW-PI-0186 Personal Injury Forms (NSW) Page 2 of 6

3 Motor Accident Forms >> MAA - Claims Assessment Resolution Service - CARS Forms Application for Exemption for a Compensation to Relatives Claim Form 1A CTR LL-NSW-PI-0058 Application for Exemption for a Personal Injury Claim Form 1A PIC LL-NSW-PI-0057 Application for Further General Assessment Form 3A LL-NSW-PI-0060 Application for General Assessment Form 2A LL-NSW-PI-0059 Application for Special Assessment Form 5A LL-NSW-PI-0061 CARS (applications) extra docs CARS (replies) extra docs Reply to Application for Exemption for a Compensation to Relatives Claim Form 1R CTR LL-NSW-PI-0184 LL-NSW-PI-0185 LL-NSW-PI-0063 Reply to Application for Exemption for a Personal Injury Claim Form 1R PIC LL-NSW-PI-0062 Reply to Application for Further General Assessment Form 3R LL-NSW-PI-0065 Reply to Application for General Assessment Form 2R LL-NSW-PI-0064 Reply to Application for Special Assessment Form 5R LL-NSW-PI-0066 Motor Accident Forms >> MAA - Claims Assessment Resolution Service - CARS Forms >> Replies for use with pre 1 October 2008 Applications Reply to Application for Exemption for a Compensation to Relatives Claim Form 1R CTR LL-NSW-PI-0173 Reply to Application for Exemption for a Personal Injury Claim Form 1R PIC LL-NSW-PI-0172 Reply to Application for Further General Assessment Form 3R LL-NSW-PI-0175 Reply to Application for General Assessment Form 2R LL-NSW-PI-0174 Reply to Application for Special Assessment Form 5R LL-NSW-PI-0176 Motor Accident Forms >> MAA - Medical Assessment Service - MAS Forms Application for a Referral to the Medical Assessment Service by a CARS Assessor or Court Form 6A LL-NSW-PI-0051 Application for a Review of a Medical Assessment Form 5A LL-NSW-PI-0050 Application for Assessment of a Permanent Impairment Dispute Form 2A LL-NSW-PI-0047 Application for Assessment of a Treatment Dispute Form 1A LL-NSW-PI-0046 Application for Further Assessment of a Permanent Impairment Dispute Form 4API LL-NSW-PI-0049 Application for Further Assessment of a Treatment Dispute Form 4AT LL-NSW-PI-0179 MAS (applications) extra docs MAS (replies) extra docs LL-NSW-PI-0180 LL-NSW-PI-0181 Reply to an Application for a Review of a Medical Assessment Form 5R LL-NSW-PI-0056 Reply to an Application for Assessment of a Permanent Impairment Dispute Form 2R LL-NSW-PI-0053 Reply to an Application for Assessment of a Treatment Dispute Form 1R LL-NSW-PI-0052 Reply to an Application for Further Assessment of a Permanent Impairment Dispute Form 4RPI LL-NSW-PI-0055 Reply to an Application for Further Assessment of a Treatment Dispute Form 4RT LL-NSW-PI-0182 Reply to an Application for Referral to the Medical Assessment Service by a CARS Assessor or Court Form 6R LL-NSW-PI-0183 Motor Accident Forms >> MAA - Medical Assessment Service - MAS Forms >> Replies for use with pre 1 October 2008 Applications Reply to Application for a Review of a Medical Assessment Form 5R LL-NSW-PI-0171 Reply to Application for Assessment of a Permanent Impairment and or Stabilisation Dispute Form 2R LL-NSW-PI-0168 Personal Injury Forms (NSW) Page 3 of 6

4 Reply to Application for Assessment of a Treatment Dispute Form 1R LL-NSW-PI-0167 Reply to Application for Assessment of an Earning Capacity Dispute Form 3R LL-NSW-PI-0169 Reply to Application for Further Assessment of a Medical Dispute Form 4R LL-NSW-PI-0170 Victims Compensation Correspondence >> Client Letter to Client - will advise of progress Letter to Client when applying for leave to extend time limit - will notify when a hearing - LLSPI149 LLSPI49 date has been allocated Victims Compensation Correspondence >> Tribunal Letter to Tribunal enclosing Application for Compensation Letter to Tribunal enclosing further doctor s reports Victims Compensation Tribunal Forms Application for Compensation and or Expenses Application for Compensation by a Family Member of a Homicide Victim Application for Counselling by a Family Member of a Homicide Victim Application for Funeral Expenses Application for Initial 2 hours of Counselling Consent Form Injury Nomination Bridging Form Request for Further Hours of Approved Counselling Victims Assistance Scheme (VAS) Supplementary Form Workers Compensation Commission Forms LL-NSW-PI-0100 LL-NSW-PI-0102 LL-NSW-PI-0103 LL-NSW-PI-0104 LL-NSW-PI-0082 LL-NSW-PI-0086 LL-NSW-PI-0085 LL-NSW-PI-0087 LL-NSW-PI-0080 LL-NSW-PI-0088 LL-NSW-PI-0083 LL-NSW-PI-0081 LL-NSW-PI-0084 Agreement to Discontinue Proceedings Form 14A LL-NSW-PI-0040 Appeal Against a Decision of Approved Medical Specialist Form 10 LL-NSW-PI-0031 Appeal Against Decision of Arbitrator Form 9 LL-NSW-PI-0029 Application for Assessment by an Approved Medical Specialist Form 7 LL-NSW-PI-0023 Application for Assessment of Costs - Schedule 6 after Form 15A LL-NSW-PI-0042 Application for Assessment of Costs - Schedule 6 before Form 15 LL-NSW-PI-0189 Application For Determination to Commute Liability Form 5C LL-NSW-PI-0020 Application for Expedited Assessment Form 1 LL-NSW-PI-0001 Application for Leave to Refer a Question of Law Form 13 LL-NSW-PI-0038 Application for Leave to Serve a Direction for Production Outside the State Form 8A LL-NSW-PI-0027 Application for Mediation to Resolve Work Injury Damages Claim Form 11C LL-NSW-PI-0036 Application to Admit Late Documents Form 2C LL-NSW-PI-0016 Application to Cure a Defective Pre-Filing Statement Form 11B LL-NSW-PI-0035 Application to Determine to Redeem Liability Form 5D LL-NSW-PI-0021 Application to Join a Party to Proceedings Form 2B LL-NSW-PI-0015 Application to Register a Commutation Agreement Form 5A LL-NSW-PI-0018 Application to Register a Redemption Agreement Form 5B LL-NSW-PI-0019 Application to Resolve a Dispute Form 2 LL-NSW-PI-0004 Application to Resolve a Workplace Injury Management Dispute Form 6 LL-NSW-PI-0022 Application to Revoke an Interim Payment Direction Form 1A LL-NSW-PI-0002 Certificate of Service for Work Injury Damages Claims Form 11A LL-NSW-PI-0034 Personal Injury Forms (NSW) Page 4 of 6

5 Certificate of Service Form 4 LL-NSW-PI-0017 Consent Orders LL-NSW-PI-0044 Cover - Additional Insurer or Scheme Agent Form 2 LL-NSW-PI-0013 Cover - Multiple Employers Form 2 LL-NSW-PI-0010 Cover - Section 162 Form 2 LL-NSW-PI-0011 Cover - Uninsured Employer Form 2 LL-NSW-PI-0012 Direction for Access to Information and Premises Form 11 LL-NSW-PI-0033 Direction for Production - with schedules Form 8 LL-NSW-PI-0026 Direction for Production Form 8 LL-NSW-PI-0025 Election to Discontinue Proceedings Form 14B LL-NSW-PI-0041 Notice for Production Notice of Opposition to Appeal Against Decision of Approved Medical Specialist Form 10A LL-NSW-PI-0045 LL-NSW-PI-0032 Notice of Opposition to Appeal Against Decision of Arbitrator Form 9A LL-NSW-PI-0030 Notice of Opposition to Application for Leave to Refer a Question of Law Form 13A LL-NSW-PI-0039 Notice to Producer or Witness LL-NSW-PI-0160 Reply to Application for Expedited Assessment Form 1B LL-NSW-PI-0003 Reply to Application to Resolve a Dispute Form 2A LL-NSW-PI-0014 Response to an Application for Mediation to Resolve Work Injury Damages Claim Form 11D LL-NSW-PI-0037 Response to Application for Assessment by an AMS Form 7A LL-NSW-PI-0024 Summons to Attend Form 8B LL-NSW-PI-0028 Wages Schedule Form 18 LL-NSW-PI-0043 Workers Compensation Correspondence - Acting for Applicant >> Client Letter to Client advising Arbitrator to Determine on On the Papers basis Letter to Client advising of Arbitration date Letter to Client advising of Teleconference Letter to Client confirming receipt of advice the Insurer stopped payments Letter to Client enclosing copy of Reply Letter to Client enclosing Stamped copy of Application Workers Compensation Correspondence - Acting for Applicant >> Doctor Letter to qualifying doctor confirming medical appointment and request for report Workers Compensation Correspondence - Acting for Applicant >> Respondent's Insurer Letter to Respondent Insurer enclosing Application to Resolve a Dispute Workers Compensation Correspondence - Acting for Applicant >> Respondent's Solicitor Letter to Respondent s Solicitor Requesting Medical Reports Workers Compensation Correspondence - Acting for Applicant >> WorkCover Letter to WorkCover requesting Respondents Insurer details Workers Compensation Miscellaneous Documents Authority to Receive Settlement Money Authority to Settle Common Law Action Brief to Counsel LL-NSW-PI-0115 LL-NSW-PI-0114 LL-NSW-PI-0116 LL-NSW-PI-0111 LL-NSW-PI-0113 LL-NSW-PI-0112 LL-NSW-PI-0119 LL-NSW-PI-0118 LL-NSW-PI-0117 LL-NSW-PI-0120 LL-NSW-PI-0156 LL-NSW-PI-0155 LL-NSW-PI-0158 Personal Injury Forms (NSW) Page 5 of 6

6 Community Relations Commission Interpreter Request Form Election by client to claim damages at Common Law Workers Compensation Complying Agreement pursuant to s66a LL-NSW-PI-0162 LL-NSW-PI-0154 LL-NSW-PI-0157 Note: In addition to the above forms, this profile may include shortcuts to forms which are not included with this subscription. Those shortcuts will require a separate subscription with the profile containing the original forms Personal Injury Forms (NSW) Page 6 of 6

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