Fast track serious injury application form

Fast track serious injury application from: Supplementary common law protocols

Important notes:

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

Please ensure your fast track application meets the criteria outlined in Clause 3.3 and Chapter 5 of the Supplementary Common Law Protocols.

Please ensure your application meets the criteria outlined in Clause 3.3 and Chapter 5 of the Supplementary Common Law Protocols.

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.

Defendant 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

Demonstrable serious injuries

List only the clearly demonstrable serious injuries relied on by the client (not every injury) and the relevant sub paragraphs of the definition of serious injury in Section 93(17) of the TAA.

Injury *

Relevant subparagraph of Section 93 (17) *

Please consider submitting scar photos with your Serious Injury application.

I confirm that an Impairment Protocols application has not been lodged. *

I acknowledge that the impairment process will be deemed to be bypassed with the applicable costs uplift from Clause 21.15 of the 2016 Common Law Protocols payable at settlement. *

Is the claim limited to pain and suffering damages *

YesNo

Schedule of documents relied upon

Please supply a full schedule of documents relied upon for this fast track 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

If you have any documents you are relying on, but haven’t already submitted to the TAC, please check below and upload your documents:

Accident circumstances, liability reports or witness statements

Accident circumstances, liability reports or witness statements upload *

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List of Accident circumstances, liability reports or witness statements

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Medical material (treaters, JMEs, IMEs, operation reports, radiology results etc.)

Medical material upload *

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List of your medical material

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Scar sight photos (current photos of scarring are required)

Scar sight photos upload *

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List of your scar sight photos

{{financial documentation upload}}

Guardian / Administrator

Has the client had an administrator appointed? *

YesNo

Please upload supporting material *

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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 this application, 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

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).

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