Can the TAC help you?

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 1300 654 329. Telephone 1300 654 329 STD Toll free 1800 332 556 tac.vic.gov.au ABN 22 033 947 623

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: Email address Do you consent to the TAC communicating: With you via SMS? With you via Email? 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 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

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

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

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

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) Email 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 www.tac.vic.gov.au or by calling the TAC contact centre on 1300 654 329) To finish your application, please proceed to the next page and complete the declaration and authority to release information.

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 1986. Relationship to claimant (e.g. parent/guardian, administrator or power of attorney) Dated (DD/MM/YYYY)

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?