Authority to release information (client representative)

This form allows you to nominate another person to act on your behalf about your TAC claim, and discuss your TAC claim with TAC employees.

We treat your personal information in confidence and in line with the TAC privacy policy.

Please note: We will never ask you to disclose passwords or transfer funds into an unknown bank account. Please contact us if you have any concerns.

1. Client details

First name *

Last name *

Date of birth *

TAC claim number *For example, 00/00000

Date of accident *

Email

Phone

Address *

Street address *

City *

State *

Postcode *

2. Representative's details

Representative's first name *

Representative's last name *

Representative's phone number *

Representative's email

Representative's relationship to you *

Other, please specify *

Representative's address *

Street address *

City *

State *

Postcode *

3. Nomination details

When can the person(s) nominated in this form be contacted? *

Only when you cannot be reachedCan be contacted at any time

What would you like the above person(s) to do on your behalf?

Receive all correspondence on your behalfMake decisions about your TAC claim, such as requesting treatment and servicesRequest personal and health information about youChange your personal details, including your contact details and bank account details

Select all that apply. If no boxes are selected, your preferences will default to all options above.

4. Your signature

Please sign in the box below *

Clear

Use your mouse, your finger or a stylus on a touch screen to sign.

Name *

Date *

You can change or revoke this consent at any time by contacting the TAC. If you have a claims manager, you can contact them directly, or email info@tac.vic.gov.au

Important information

Your privacy

The TAC will retain the information provided and may use or disclose it to make further inquiries or assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information.

If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our website at tac.vic.gov.au/privacy