THE LAW SOCIETY OF THE AUSTRALIAN CAPITAL TERRITORY

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1 Complee he form in BLOCK LETTERS Provide deails on separae shees if required To Responden Address THE LAW SOCIETY OF THE AUSTRALIAN CAPITAL TERRITORY Personal Injury Claim ificaion pursuan o he Civil Law (Wrongs) Amendmen Regulaion 2004 Name of firm Name of solicior Poscode 1. Your personal deails Mr Mrs Miss Ms Oher Dae you firs consuled a solicior Dae you firs idenified he responden 2. Acciden/Inciden Deails How were you injured? Dae of birh Moor Vehicle Acciden Work Acciden Healh Providers Ac or Omission Public Liabiliy Oher Posal address or as above Poscode Dae of acciden Time of acciden am pm Place of acciden (include sree and own if applicable) Poscode Poscode Please provide a descripion of he acciden Have you even been known by anoher name? Give deails below Are you legally represened? Give deails G /04

2 Do you know if police, ambulance, fire brigade or any oher emergency service aended he acciden? Name of service Give deails below Who in your opinion, oher han he responden, caused he acciden? Name of person who aended Poscode Conac deails Are you receiving, or eniled o, any oher forms of compensaion as a resul of his acciden? (For example, workers compensaion) Do you know if any winess saemens were aken (for example by police)? Winess 1 Give deails below Give deails below Name of insurance company Type of policy Policy/Claim number Have you lodged a claim? Winess 2 Poscode Give deails below Dae claim lodged Claim number 3. Medical Deails Wha are your injuries from he acciden? (lis all injuries) Poscode

3 Did you go o hospial afer he acciden? Please provide your employmen deails Name of hospial Name of employer Dae Who has reaed you for your injuries since he acciden? Lis all docors, surgeons, physioherapiss, specialiiss ec. (Please include annexure if here is no enough room) Conac person s name Conac phone number Workplace address Name Poscode Address (pracice or surgery) Usual weekly working hours Ordinary Overime Phone number Poscode Wha reamen or rehabiliaion have you had? Usual weekly earnings (include overime, regular bonuses and commission) Gross (before ax) Ne (afer ax) $ $ Descripion of duies 4. Employmen deails Have you los income as a resul of his acciden/inciden? Is he work you do or your weekly earnings differen because of he acciden? Give deails below Please advise your employmen saus Full ime employed Par ime employed Self employed Casual Reired Suden/Child Home duies working Pension (please describe) Oher (please describe) If self employed: Have you los income from self employmen in your own business because of he acciden? Give deails below

4 Name and naure of business Name of service provider Accounans name Dae Time am pm Place Accounans conac deails Did he healh service provider provide any wrien or oral informaion or warning? Phone number If yes, please provide deails Esimae of earning loss (if known, give deails of how much you believe you have los and how you calculaed he amoun. You mus be able o give copies of your axaion reurns, group cerificaes and assessmen noices). $ Dae Place Time am pm Warning given: 5. Claim agains healh service providers Is he claim agains a healh service provider? (eg a docor) If yes, wha is he medical condiion for which you sough reamen? Is he claim relaed o a new injury or he worsening of a pre-exising injury? New Pre-Exising Wha did he healh service provider do or no do which caused he injury or worsened a pre-exising injury? Did you consen o he reamen given o you by he healh service provider which has given rise o he injury? Was i wrien or oral consen? Wrien Oral Do you believe he healh service provider failed o inform you of he risks involved in he reamen you underook? When and where was he consen given? Place If yes, please provide deails as o when you believe he informaion should have or could have been provided o you Dae

5 Moor Vehicle Accidens If he injury was caused by a moor vehicle acciden, please complee he following quesions oherwise urn o he nex page Do you have he regisraion number of he vehicle you consider a faul? There is an obligaion on you as he claiman o provide evidence of seps aken o find ou he regisraion number or he owner of he vehicle you consider a faul. Please lis any acion aken by you o find he regisraion number or he name of he person who drove he vehicle you consider a faul. (Please aach any proof such as newspaper adverisemen or discussions wih any winesses ec) Type of vehicle (if known) Vehicle you were ravelling in Regisraion number Type of vehicle If you were a driver/passenger, were you wearing a sea bel? If you were a moorbike rider/cyclis, were you wearing a helme? Regisraion number Give deails below Diagram of Acciden Draw a diagram of he acciden. Include all inersecions, srees, roads and heir names. Show he poin of impac and posiion of vehicles. Use his box Symbols vehicle ha caused he acciden oher vehicle(s) ec pedesrian, cyclis, ec Example diagram Inersecion Souh Sree Eas Road 2 1 Poin of impac

6 Auhorisaion Signaure of injured person address Poscode *If anoher person signed on behalf of he injured person. Deails of he person who signed auhorise he responden and he responden s insurer for he claim (if any) o have access o he following records and sources of informaion relevan o he claim which occurred on: Relaionship o he injured person 1) Clinical noes in he possession of a healh service provider who reaed or assessed he injured person for he pre-exising injury or condiion 2) Clinical noes in he possession of a hospial (including a privae hospial) where he inured person received reamen relevan o he personal injury 3) Records in he possession of an ambulance or oher emergency service ha reaed or assised he injured person in relaion o he personal injury 4) Clinical noes in he possession of a healh service provider who reaed or assessed he injured person in relaion o he personal injury 5) Wage, leave and work hisory records in he possession of (i) he injured person s employer (ii) anyone else who employed he injured person a any ime during he 3 years before he acciden. The responden and he responden s Insurer (if any) mus no use records and sources of informaion accessed under sub regulaion (1) oherwise han for a purpose relaed o he claim. The person mus provide he injured person wihin one monh wih copies of any documens obained pursuan o his auhorisaion. Reason why he injured person could no sign Documens o accompany noice of claim The noice of claim mus be accompanied by he following documens: a) for a claim oher han a claim agains a healh service provider a copy of any cerificae signed by a docor relevan o he personal injury o which he claim relaes ha is in he claiman s possession. b) for a claim agains a healh service provider a copy of any advice or warnings given o he injured person by he healh service provider abou he reamen claimed o have given rise o he personal injury ha is in he claiman s possession. c) for a claim agains a healh service provider a copy of any consen given o he healh service provider by he injured person abou he reamen claimed o have given rise o he personal injury ha is in he claiman s possession. d) a copy of any oher documen on which he claiman currenly expecs o rely for he claim ha is in he claiman s possession.

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