TAC Funeral and dependency benefits claim form

The TAC is here to help you at this difficult time.

We can provide financial support to help cover funeral costs, counselling services, and support for dependents. The amount of support available will depend on your family's circumstances.

To access support from the TAC, please complete the form below.

This form collects important details about your loved one and the accident. We use this information to understand your situation and determine the ways we can support you.

Instructions

If you need help to complete this form, please call the TAC's Family Benefits team on 03 5225 6200.

You can make a TAC claim up to one year after the accident. It is best to make a claim as soon as you can. This will ensure you receive the benefits you are entitled to as quickly as possible.

Details of the person who died in the transport accident

Title *

First name *

Middle name

Last name *

Date of birth *

Home address *

Street name and number *Street address line 2

City *

State *

Postcode *

Country

Gender *

Preferred pronouns

Marital status *

Other *Please describe the person's marital status

Country of birth

Cultural background or ethnicity

Did the person who died identify as an Aboriginal and/or Torres Strait Islander?

Transport accident details

Date and time of the transport accident *

Location of the transport accident *Please provide as much detail as possible, including the street number, street name, town or suburb, state and postcode where the accident happened.

Did police attend the accident? *

YesNoDon't know

Police report number

Police officer name

Police officer badge number

At the time of the accident, what type of transport user was the person who died? *

Other *

Which public transport company operates the vehicle?For example, Yarra trams, Metro trains, V/line

Registration of vehicle

State vehicle was registered in

Type of vehicle involved

Type of vehicle

Other type of vehicle *

Vehicle make and model

Was the person who died on their way to or from work when the accident happened? *

YesNo

Was the person who died working when the accident happened? *

YesNo

Was the person who died taking part in, or in a test in preparation for a motor vehicle race, speed trial, enduro, or rally? *

YesNo

Injury details

Date of death (if different from date of accident)

Place of deathFor example, Hospital, scene of accident, at home

Please list any health conditions the person who died had before the accident

Spouse, partner and dependent children details

Did the person who died have a spouse, partner or dependent children ? *

YesNo

Dependant's statutory declaration

A dependant spouse or partner of the person who died can complete a Dependant's statutory declaration.

If completed, a statutory declaration must be signed and witnessed before being sent to the TAC.

The TAC will use the Dependant's statutory declaration to determine dependency benefits for a dependant spouse or partner.

Download a copy of the Dependant's statutory declaration.

If you have a completed and signed Dependant's statutory declaration, you can upload it here

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Family member details

Please complete the family member information below.

The TAC needs this information to make decisions about your entitlement to TAC benefits and services. We may use or disclose this information 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. Without this information, the TAC may be unable to determine entitlements or assess whether treatment is reasonable and may not be able to approve further benefits and treatment. More information is available at tac.vic.gov.au/yourprivacy.

Family member 1

Title *

First name *

Last name *

Date of birth

Phone number *

Email

Home address *

Street name and number *

City *

State *

Postcode *

Country

Relationship to the person who died *

Gender

Preferred pronouns

Was this person a full-time student or apprentice at the time of the accident? *

Does this family member identify as an Aboriginal and/or Torres Strait Islander?

Country of birth

Cultural background or ethnicity

Preferred language

Does this family member need an interpreter?

YesNo

Add another family member? *

YesNo

Family member 2

Title *

First name *

Last name *

Date of birth

Phone number *

Email

Home address *

Street name and number *

City *

State *

Postcode *

Country

Relationship to the person who died *

Gender

Preferred pronouns

Was this person a full-time student or apprentice at the time of the accident? *

Does this family member identify as an Aboriginal and/or Torres Strait Islander?

Country of birth

Cultural background or ethnicity

Preferred language

Does this family member need an interpreter?

YesNo

Add another family member? *

YesNo

Family member 3

Title *

First name *

Last name *

Date of birth

Phone number *

Email

Home address *

Street name and number *

City *

State *

Postcode *

Country

Relationship to the person who died *

Gender

Preferred pronouns

Was this person a full-time student or apprentice at the time of the accident? *

Does this family member identify as an Aboriginal and/or Torres Strait Islander?

Country of birth

Cultural background or ethnicity

Preferred language

Does this family member need an interpreter?

YesNo

Add another family member? *

YesNo

Family member 4

Title *

First name *

Last name *

Date of birth

Phone number *

Email

Home address *

Street name and number *

City *

State *

Postcode *

Country

Relationship to the person who died *

Gender

Preferred pronouns

Was this person a full-time student or apprentice at the time of the accident? *

Does this family member identify as an Aboriginal and/or Torres Strait Islander?

Country of birth

Cultural background or ethnicity

Preferred language

Does this family member need an interpreter?

YesNo

Add another family member? *

YesNo

Family member 5

Title *

First name *

Last name *

Date of birth

Phone number *

Email

Home address *

Street name and number *

City *

State *

Postcode *

Country

Relationship to the person who died *

Gender

Preferred pronouns

Was this person a full-time student or apprentice at the time of the accident? *

Does this family member identify as an Aboriginal and/or Torres Strait Islander?

Country of birth

Cultural background or ethnicity

Preferred language

Does this family member need an interpreter?

YesNo

Add another family member? *

YesNo

Family member 6

Title *

First name *

Last name *

Date of birth

Phone number *

Email

Home address *

Street name and number *

City *

State *

Postcode *

Country

Relationship to the person who died *

Gender

Preferred pronouns

Was this person a full-time student or apprentice at the time of the accident? *

Does this family member identify as an Aboriginal and/or Torres Strait Islander?

Country of birth

Cultural background or ethnicity

Preferred language

Does this family member need an interpreter?

YesNo

Add another family member? *

YesNo

Add more family members *For each extra family member, please include: Name, date of birth, phone number, home address, their relationship to the person who died and whether or not they were a full-time student or apprentice at the time of the accident.

Work details

At the time of the accident, what was the occupation of the person who died? *

Employment details

Job title

How long did the person who died work for this employer?

Name of employer

Employer's address

Employer's email

Employer's contact phone number

Self-employed details

Name of business

ABN

Address of business

Funeral director details

Funeral director first name

Funeral director last name

Name of funeral home

Funeral home address

Street name and number

City

State

Postcode

Phone number

Email

More information

NotesPlease use this section to record any other information relevant to the claim. Please also include details of previous spouse, partner or children, if relevant. If the person who died has no dependents, please note this and include contact numbers of the deceased’s closest relative and/or friends (up to three names), or a guardian’s contact details for dependent children.

Declaration of the person completing this form

Is the funeral director completing this form? *

YesNo

Email *

Next of kin details

Next of kin first name *

Next of kin last name *

Date of birth

Relationship to the person who died *

Phone number *

Email *

Next of kin address *

Street address *

City *

State *

Postcode *

Person completing form details

First name *

Last name *

Date of birth *

Your relationship to the person who died *

Phone number *

Email *

Address *

Street name and number *

City *

State *

Postcode *

I declare that the information provided in this claim for compensation is true and correct. *

Your signature *

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Privacy

The TAC will use the information we collect on this form to make decisions about a person’s entitlement to TAC services and benefits.

We may use or disclose this information to make further inquiries or assist in the ongoing management of the TAC claim.

The TAC may also be required by law to disclose this information.

More information is available at tac.vic.gov.au/yourprivacy

Save and Complete Later

Instructions

Details of the person who died in the transport accident

Transport accident details

Injury details

Spouse, partner and dependent children details

Dependant's statutory declaration

Family member details

Family member 1

Family member 2

Family member 3

Family member 4

Family member 5

Family member 6

Work details

Employment details

Self-employed details

Funeral director details

More information

Declaration of the person completing this form

Next of kin details

***Person completing form details***

Privacy

Save and Complete Later

Person completing form details