Impairment application form

IMPAIRMENT APPLICATION FORM: IMPAIRMENT ASSESSMENT PROTOCOLS

Important notes:

This form is to be used by lawyers requesting an impairment assessment on behalf of a client under Part 3 of the Transport Accident Act 1986 (TAA) and pursuant to the Impairment 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 age

Is client under 18 years of age

Does the client have any other TAC claims? *

YesNoNot known

TAC claim number

Is this claim part of this application? *

YesNo

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.

Client's injuries

Please list your client's injuries or conditions and indicate which TAC claim number they relate to.

Injury

TAC claim number for this injury

Supporting documentation

Please provide the following list of documents relied upon in the application (where appropriate), only attaching copies where not previously provided to the TAC.

Check an option to upload your supporting documents.

Treating practitioner reports and material

Treating practitioner reports and material upload

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A list of your treating practitioner reports

{{treating practitioner reports and material upload}}

Medico-legal reports

Medico-legal reports upload

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A list of your medicolegal reports

{{medicolegal reports upload}}

JME reports

JME reports upload

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A list of your JME reports

{{jme reports upload}}

Other (e.g. list of documents relied upon)

Summary and analysis of impairment

The client's lawyers suggested whole person impairment percentage based on the current evidence, including reference to the relevant AMA Guides section and any other relevant information.

Injury or condition *

Rating (WPI) *

Table (AMA guides reference) *

Other relevant matters (e.g. apportionment, stability, pre-existing, causation etc.)

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? *

Guardian / Administrator

Has the client had an administrator appointed? *

YesNo

Please upload supporting material *

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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