Serious injury application form

Serious injury application form: Common law protocols

Important notes:

This form is to be used by lawyers requesting a serious injury certificate on behalf of a client under Part 6 of the Transport Accident Act 1986 (TAA) and pursuant to the Common Law Protocols 2016.

Please complete this form and provide all information and material in support of the application (not previously provided).

Client details

Client first name *

Client last name *

Date of birth *

Date of accident *

Claim number *

Client's lawyer

Firm name *

Firm address *

Street address *

City *

State *

Postcode *

Practitioner *

Reference number *

Phone number *

Fax number

Email address *We will email a copy of your application to this email address.

Serious injury claim information

Please provide the name(s) of all parties against whom a common law claim is proposed with registration details of vehicles (if known).

Defendant *

Registration details (if known)

Client's injuries

List the injuries relied on by the client and select the relevant subparagraphs of the definition of serious injury in Section 93 (17) of the TAA.

Add more lines for injuries that relate to other subparagraphs of Section 93 (17).

Injuries *

Relevant subparagraph of Section 93 (17) *

Please consider submitting scar photos with your Serious Injury application.

If liability is admitted, do you intend to bypass impairment? *

YesNo

Is the claim limited to pain and suffering damages? *

YesNo

Affidavit

Has an affidavit been sworn? *

YesNo

Date affidavit sworn *

Please upload the affidavit *

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Affidavit upload

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Please provide the reasons why an affidavit has not been sworn *

Schedule of documents relied upon

Please supply a full schedule of documents replied upon for this serious injury application.

This list should include any documents already sent to the TAC, for example during the claim lodgement or an impairment application.

Any documents not already sent to the TAC can be uploaded to this form in the next section.

Schedule of documents relied upon upload

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Schedule of documents relied upon upload

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Supporting documentation

Please check the relevant document types and only upload copies if not previously provided to the TAC .

Accident circumstances or liability report

Accident circumstances or liability report upload *

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List of accident circumstances or liability reports

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Treating practitioner reports and material

Treating practitioner reports and material upload *

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List of your treating practitioner reports

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Medico-legal reports

Medico-legal reports upload *

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List of your medico-legal reports

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JME reports

JME reports upload *

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List of your JME reports

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Scar sight photos

Scar sight photos upload *

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List of your scar sight photos

{{scar sight photos upload}}

Financial documentation

Financial documentation upload *

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List of your financial documentation

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Additional information (e.g. list of documents relied upon, school reports, lay affidavits)

Additional information upload *

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List of your additional information

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More information

Do you intend to provide any other information to support this application? *

YesNo

Please list and describe all the information you will supply *

When will you supply this information? *

Other comments

Other comments that would assist the TAC in making a serious injury decision

Guardian / Administrator

Has the client had an administrator appointed? *

YesNo

Please upload supporting material *

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Workers compensation claim details

Does the client have an accepted WorkCover claim for this accident? *

YesNoPending

WorkCover number *

Has a serious injury application been lodged or is intended to be lodged with WorkCover?

LodgedNo

Reasons why the subject accident meets the definition of a transport accident

Please provide reasons why the subject accident meets the definition of a transport accident *

Details of the claimed negligent vehicle (if known)

Registration

Make

Model

Any other identifying features of the vehicle?

The form is completed on a without prejudice basis to promote the efficient administration of the Protocols and cannot be relied upon in any later Court or Tribunal proceedings (unless otherwise agreed).

The TAC’s privacy policy

The TAC respects the privacy of clients. The TAC will retain any information provided to the TAC as part of the JME process, and may use or disclose that information to make further inquiries or assist in the ongoing management of the client’s TAC claim. The TAC may also be required by law to disclose any information provided to the TAC.

If you require further information about the TAC’s Privacy Policy, please call the TAC on 1300 654 329 or visit our website at tac.vic.gov.au/yourprivacy

Internal TAC reference, please ignore

Information about using the 'Save and complete later' feature

You must not attach documents to this form until you are ready to submit.

Any attachments uploaded and saved without submitting are added at the user's risk, and the security of the information saved cannot be guaranteed by the TAC until the form is submitted.

Save and Complete Later