Transport Accident (Amendment) Regulations 1999 (Vic)

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Transport Accident (Amendment) Regulations 1999

S.R. No. 64/1999

TABLE OF PROVISIONS

Regulation Page

1. Objective 1
2. Authorising provision 1
3. Commencement 1
4. New Form 5 substituted 1
5. Amendments to Form 6 2

__________________

SCHEDULE 3

Form 5—Claim for compensation under the Transport Accident Act

1986 3

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NOTES 11

i

STATUTORY RULES 1999

S.R. No. 64/1999

Transport Accident Act 1986

Transport Accident (Amendment) Regulations 1999

The Governor in Council makes the following Regulations:
Dated: 1 June 1999
Responsible Minister:
ALAN STOCKDALE
Treasurer
SHANNON DELLAMARTA
Acting Clerk of the Executive Council

1. Objective
The objective of these Regulations is to prescribe
forms to be used for the purposes of the
Transport Accident Act 1986.

2. Authorising provision
These Regulations are made under section 132 of the Transport Accident Act 1986.

3. Commencement
These Regulations come into operation on 1 July
1999.

4. New Form 5 substituted
In the Schedule to the Transport Accident in the Schedule to these Regulations.

Transport Accident (Amendment) Regulations 1999

r. 5	S.R. No. 64/1999

5. Amendments to Form 6
In Form 6 in the Schedule to the Transport
Accident Regulations 1996—

(a)
COMPENSATION (FATAL)" substitute
"FUNERAL AND DEPENDENCY
in the heading to the form, for "CLAIM FOR COMPENSATION"; and

(b)

omit "If deceased was travelling in a car or motor cycle, please mark the position".

__________________
Transport Accident (Amendment) Regulations 1999

Sch.
Sch.

S. R. No. 64/1999
SCHEDULE

Form 5

CLAIM FOR COMPENSATION UNDER THE TRANSPORT

ACCIDENT ACT 1986

PERSONAL DETAILS

1. Surname
Title
Given names
Male/Female Date of Birth E-Mail Address
Home phone Address
Work phone
Mobile phone Fax number
If you have been known by another name or have changed your name in the past 5 years, please provide details below—

Surname Given names

2.
Were any members of your family involved in the transport accident? If yes, please provide details below—

Relationship i.e. Have
sister, parent, they
spouse, brother, made a

Full Name Address Date of Birth child, other claim?

3.

Do you need an interpreter?

5.

If you are entitled to TAC benefits, do you want them deposited directly into
No (go to 4) your bank account?
Yes—Language spoken No (go to 6)
4. Have you received or applied for If yes, please provide details of
Social Security or Centrelink account—
payments—

• Name in which the account is

• because of the transport accident? held

• in the six months before the • BSB number (6 digits in total)

accident? If yes, what type of benefit?

•

Account number (up to 10 digits)
• Bank name
Centrelink/Social Security Reference • Branch
No.
• Address

Transport Accident (Amendment) Regulations 1999

Sch.	S.R. No. 64/1999

6.

Did Police attend the scene of the accident?

14. Were you the driver of the vehicle? Yes (go to 15)
No (go to 7)

If no, provide the following details—

Yes—Police Officer's Name • Driver's surname
Stationed at • Driver's given names

7. I reported the accident to the Police on • Driver's address
[date] to [Police Officer's name], • Home phone
stationed at [name of Police Station]
• Work phone
Station book number • Mobile phone

TRANSPORT ACCIDENT DETAILS 15. Details of the vehicle you were travelling in—
8. Provide the following details—

• Registration number

• Date of accident

• Was the vehicle registered in

• Day of week
Victoria: If no, what State was

• Accident time am/pm the vehicle registered in?

• Where did the accident happen? • Make and model of vehicle
• Please describe how the accident (e.g. Holden Gemini)
happened • Name of company if train/tram
• Please draw a diagram showing involved
how the accident happened
(All passengers go to 18)

9. In the accident, were you a—
16. Were you the owner of the vehicle

• Driver (go to 10) you were driving?
• Car or truck passenger Yes (go 17)
(go to 10)
If no, did you have permission to use
• Motorcyclist (go to 10)
the vehicle?
• Pillion passenger (go to 10)
17. Please provide your licence details—

• Tram passenger (go to 15)

• Licence or permit number

• Train passenger (go to 15)

• Expiry date of licence or permit

• Bus passenger (go to 15)

• Length of time licence or permit

• Cyclist (go to 18)
has been held

• Pedestrian (go to 19)
18. Were you wearing a seatbelt or

• Other (go to 18) helmet?

10. What was your position in the vehicle immediately before the accident?

19. Is Police action going to be taken in relation to the accident?

11. If travelling in a car, were you thrown out of the vehicle due to the accident? No (go to 20)
If yes, name of person charged
12. Were you involved in a collision with

a fixed object? 20. Had you consumed any alcohol in the two hours before the accident?
13. What was the speed limit at the

accident location? No (to 21)
If yes, type and amount consumed

Transport Accident (Amendment) Regulations 1999

S.R. No. 64/1999

21. Was a breath or blood test 28. Were you transported by ambulance

undertaken? from the accident scene?

No (go to 22) 29. Were you taken to hospital?

If yes, what was your reading? No (go to 30)

22. Had you consumed any drugs If yes, provide details below—

(including medication) in the two • Hospital Name
hours before the accident?
• Date admitted
No (go to 23) • Have you been discharged from
If yes, type and amount consumed hospital?

23. Did the accident occur on the way to If yes, date discharged

or from work? 30. List all your transport accident

24. Did the accident occur while injuries

performing your daily work duties? 31. Did you sustain an injury to the head?

25. Were you taking part in, or in a test in preparation for, a motor vehicle race,

32. Did you lose consciousness?

speed trial, enduro or rally? No (go to 33)

26. Was any other vehicle involved in the Don't know (go to 33)
accident?

If yes, for how long? (hours/minutes)

No (go to 27)
33. Are you still receiving or expect to

If yes, provide the following details— receive treatment for your transport
accident injuries?

• Driver's surname
•

Driver's given names No (go to 35)
•

Driver's address If yes, please provide details of the doctor who is treating your injuries—
• Home phone

• Doctor's name

• Work phone

• Doctor's address

• Mobile phone

• Doctor's telephone number

• Registration number
•

Was the vehicle registered in 34. Is this your usual doctor?
Victoria? If no, what State was

the vehicle registered in? Yes (go to 35)
•

Make and model of vehicle If no, please provide your usual
(e.g. Holden Gemini) doctor's details—

• Doctor's name

27.

Were there any witnesses to the accident?

•

Doctor's address
No (go to 28) • Doctor's telephone number

If yes, please provide details—

35. Has the transport accident affected any injury or condition you had

• Surname before the accident?
• Given names
No (go to 36)
• Address
If yes, please provide details of the
• Home phone
injury or condition and the treatment
• Work phone and medication you were taking

Transport Accident (Amendment) Regulations 1999

Sch.	S.R. No. 64/1999

before the accident

• Mobile phone

36. Before the accident, have you ever required treatment—

39. Before the accident, did you have
home service, gardening or child
minding assistance?

• by a chiropractor or

physiotherapist? No (go to 40)
•

by a psychologist or psychiatrist? If yes, type of service and number of
•

involving orthopaedic or spinal hours per week
surgery?
40. Have you ever had a Workers

• involving hospitalisation in the Compensation Claim?
last 5 years?
No (go to 41)
• causing more than 4 weeks off
work for a medical condition? If yes, please provide the following
details—
37. Before the accident, have you ever

suffered from any of the following • Number of previous claims
conditions or problems? • Claim number

• Lower back condition or pain • Date of injury or incident
• Neck condition or pain • Injuries
• Head injury or neurological • Insurance company/employer
condition

• Settlement date

• Vascular condition
41. Have you ever had a Personal Injury

• Psychological or psychiatric

treatment or condition Claim?
•

Hip, knee or shoulder condition No (go to 42)
or pain
If yes, please provide the following

• Drug dependency (specify drug) details—
• Developmental or cognitive

• Number of previous claims
problems

• Claim number
• Arthritis

• Date of injury or incident
• Orthopaedic or spinal injury

• Injuries
• Work related injury

• Insurance company or employer
• Epilepsy

• Settlement date
• Migraine or similar episodic

headache OCCUPATION OR EMPLOYMENT
DETAILS

• Asthma
42. What was your occupation at the time of the accident?

• Heart condition
• Diabetes
Are you an employee or self-

38. Did you answer "yes" to any part of question 36 or 37?

employed?
43. Please provide details of all persons

No (go to 39) who are wholly or partly dependent
If yes, please provide details of the on you—
injury or condition and the treatment

• Name
and medication you were taking

• Date of birth
before the accident

• Relationship to you

Transport Accident (Amendment) Regulations 1999

S.R. No. 64/1999 Sch.

• Address (if not normally resident
with you)
• Is dependent person a full time
student?

Unemployed details Self-Employed details

44. Did your injuries prevent you from 48. Please provide the following details—

looking for work? • Type of business
No (go to 63) • Business name and address
If yes, how long? (weeks). • What is the status of the business
(e.g. sole trader, partnership,
Are your injuries still preventing you trust, company)?
from looking for work?
49. Estimate the loss suffered by the

45. Did you work during the two years before the accident?

business as a result of the accident
Has the business ceased completely

No (go to 46) since the accident?

If yes, provide the following details—

50.

Have you lodged any taxation returns for the last 3 financial years?

• Employer's name
•

Date employed from 51. Have you employed substitute
labour? No (go to 52)
• Date employed to

46. At the time of the accident had you received an offer of employment?

If yes, please provide a separate
statement detailing—

• Name and address of person

No (go to 63) employed

If yes, provide the following details— • Nature of duties performed

• Employer's name • Period of each employment
• Employer's address • Gross and net wages paid each
week
• Employer's phone
• Method of taxation deductions

• Scheduled employment start date Have you started this employment? made (ie group tax, prescribed
payment certificates)

If yes, date started • Documentary evidence of
payment such as cheque butts,
If no, reason for not starting bank statements etc.

Employment Details

52.

Please provide details of other income derived from personal exertion

47.

Have you had time off work due to the transport accident injuries?

53.

Please provide details of your

No (go to 63)

accountant or the person to contact regarding your financial records—
If yes, were you absent or do you

• Name
expect to be absent from work for 5

• Address
work days or more?

• Phone number
No (go to 63)

If yes, provide details of the first five Employee Details
days of absence or expected absence.

54. Please provide the following details

Have you returned to work? If yes, regarding your employment—

Transport Accident (Amendment) Regulations 1999

Sch.

Sch.	S.R. No. 64/1999

what date did you return? If no, what • Employee number
is your expected date of return (if
• Date employment commenced
known)?
• Basis of employment (permanent,
temporary, casual)

Are you employed on a contractual 56. Have any amounts been paid to you

basis for a set period? If yes, period of by your employer in respect of your
contract? absence from work?
Are you an apprentice or trainee? If No (go to 57)
yes, provide the following details—
If yes, please provide the following

• Type of apprenticeship or details—
traineeship

• Nature of payment (eg sick leave,

• Date commenced annual leave)

• Expected completion date • Date paid from

Please provide details of your daily • Date paid to
work duties • Gross amount paid

Is the nature of the work physical or Is your employer continuing to pay
non physical? you?
Are alternative duties available to If yes, when will payment cease?
you? (e.g. light, modified)?
57. Is regular overtime a condition of

55. Please provide details of your working your employment?
week—
No (go to 58)

• Which days do you work?
•

Hours per day If yes, how much overtime do you
work on average each week?
• Starting and finishing times

Hours minutes

58. Please provide details of your weekly wage over the 6-week period immediately before the accident

Week Gross normal Shift Allowance type No. hours No. days

ending wage Overtime allowance Other allowance (ie meal) Tax worked worked

• Are you related to your

59. Please provide the following details regarding your employer—

employer? If yes, how (eg
employer is aunt)?

• Business name
60. Does your employer have a person to assist you to return to work?

• Address
• Phone number
If yes, please provide the following

• Nature of business details—
• Approximate number of

• Contact name
employees on payroll

• Phone number
• Does your employer deduct tax

by—

61.

In order to ensure that you are taxed at the appropriate rate, please provide

• prescribed payments scheme
your tax file number

• reporting payments scheme
62. Are you liable for a HECS debt as a result of tertiary studies?

Transport Accident (Amendment) Regulations 1999

S.R. No. 64/1999

OPTIONAL—EMPLOYER'S ENDORSEMENT
To assist in processing your claim more quickly, you may ask your employer or employer's representative to endorse your answers to questions 54 to 60.
The claimant has answered questions 54 to 60 and I certify that the answers to those questions are true and correct.
Employer's signature or stamp—
Name and signature of employer's representative—
63. DECLARATION AND AUTHORITY TO RELEASE INFORMATION
This declaration allows the Transport Accident Commission to obtain records or information, which may affect your claim.
I authorise the Transport Accident Commission to contact and obtain information and documents relevant to my transport accident injuries or any injury or condition that existed before the transport accident and has been effected by the transport accident from—

• any doctor, ambulance service, hospital or other health service provider
• an insurer carrying on the business of providing Worker's Compensation insurance or
motor vehicle insurance
• a department, agency or instrumentality of the Commonwealth or the State or another State
that administers Police, Health Insurance Commission payments or social welfare laws.
I further authorise the Transport Accident Commission to contact and obtain information and documents relevant to any financial loss suffered as a result of the accident from—

• my employer (or previous employer)
• my accountant
This information may be provided to the Transport Accident Commission upon being provided with a clear photocopy or imagery reproduction of this authority.
I acknowledge that this declaration is true and correct, and I make it in the belief that a person making a false declaration is liable to the penalties of perjury.
Signature of claimant
Declared at (Place of declaration)
Before
Date
Address of person declared before
Witness signature
A person authorised under section 107A(1) of the Evidence Act 1958 to witness the signing of a statutory declaration.
If the person signing the form is not the claimant—
Surname
Given names

Transport Accident (Amendment) Regulations 1999

Sch.	S.R. No. 64/1999

Address
Relationship to claimant
Signature
Reason why the claimant cannot sign

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Transport Accident (Amendment) Regulations 1999

S.R. No. 64/1999 Notes

NOTES

1 Reg. 4: S.R. No. 164/1996.

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Transport Accident (Amendment) Regulations 1999 (Vic)

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1.	Objective	1
2.	Authorising provision	1
3.	Commencement	1
4.	New Form 5 substituted	1
5.	Amendments to Form 6	2

1.	Surname Title Given names Male/Female	Date of Birth	E-Mail Address
Home phone	Address
Work phone
Mobile phone	Fax number

Relationship i.e.	Have
sister, parent,	they
spouse, brother,	made a

accident? If yes, what type of benefit?	•	Account number (up to 10 digits)
•	Bank name
Centrelink/Social Security Reference	•	Branch
No.
•	Address

6.	Did Police attend the scene of the accident?	14. Were you the driver of the vehicle? Yes (go to 15)
No (go to 7)

Yes—Police Officer's Name	•	Driver's surname
Stationed at	•	Driver's given names

7.	I reported the accident to the Police on	•	Driver's address
[date] to [Police Officer's name],	•	Home phone
stationed at [name of Police Station]
•	Work phone
Station book number	•	Mobile phone

•	Accident time	am/pm	the vehicle registered in?
•	Where did the accident happen?	•	Make and model of vehicle
•	Please describe how the accident	(e.g. Holden Gemini)
happened	•	Name of company if train/tram
•	Please draw a diagram showing	involved
how the accident happened

•	Driver	(go to 10)	you were driving?
•	Car or truck passenger	Yes (go 17)
(go to 10)
If no, did you have permission to use
•	Motorcyclist	(go to 10)
the vehicle?
•	Pillion passenger	(go to 10)

10. What was your position in the vehicle immediately before the accident?	19. Is Police action going to be taken in relation to the accident?
11. If travelling in a car, were you thrown out of the vehicle due to the accident?	No (go to 20) If yes, name of person charged

21. Was a breath or blood test	28. Were you transported by ambulance
undertaken?	from the accident scene?
No (go to 22)	29. Were you taken to hospital?
If yes, what was your reading?	No (go to 30)
22. Had you consumed any drugs	If yes, provide details below—

(including medication) in the two	•	Hospital Name
hours before the accident?
•	Date admitted
No (go to 23)	•	Have you been discharged from
If yes, type and amount consumed	hospital?
23.	Did the accident occur on the way to	If yes, date discharged
or from work?	30.	List all your transport accident
24.	Did the accident occur while	injuries

performing your daily work duties?	31. Did you sustain an injury to the head?
25. Were you taking part in, or in a test in preparation for, a motor vehicle race,	32. Did you lose consciousness?
speed trial, enduro or rally?	No (go to 33)
26. Was any other vehicle involved in the	Don't know (go to 33)

27.	Were there any witnesses to the accident?	•	Doctor's address
No (go to 28)	•	Doctor's telephone number

•	Surname	before the accident?
•	Given names
No (go to 36)
•	Address
If yes, please provide details of the
•	Home phone
injury or condition and the treatment
•	Work phone	and medication you were taking

•	Mobile phone
36. Before the accident, have you ever required treatment—	39. Before the accident, did you have

•	involving hospitalisation in the	Compensation Claim?
last 5 years?
No (go to 41)
•	causing more than 4 weeks off
work for a medical condition?	If yes, please provide the following details—

•	Address (if not normally resident with you)
•	Is dependent person a full time student?

44.	Did your injuries prevent you from	48. Please provide the following details—
looking for work?	•	Type of business
No (go to 63)	•	Business name and address
If yes, how long? (weeks).	•	What is the status of the business (e.g. sole trader, partnership,
Are your injuries still preventing you	trust, company)?
from looking for work?

45. Did you work during the two years before the accident?	business as a result of the accident
Has the business ceased completely
No (go to 46)	since the accident?

•	Employer's name	•	Period of each employment
•	Employer's address	•	Gross and net wages paid each week
•	Employer's phone
•	Method of taxation deductions

• Scheduled employment start date Have you started this employment?	made (ie group tax, prescribed
payment certificates)

If yes, date started	•	Documentary evidence of payment such as cheque butts,
If no, reason for not starting	bank statements etc.
Employment Details	52.	Please provide details of other income derived from personal exertion

what date did you return? If no, what	•	Employee number
is your expected date of return (if
•	Date employment commenced
known)?
•	Basis of employment (permanent, temporary, casual)

Are you employed on a contractual	56. Have any amounts been paid to you
basis for a set period? If yes, period of	by your employer in respect of your
contract?	absence from work?
Are you an apprentice or trainee? If	No (go to 57)
yes, provide the following details—
If yes, please provide the following

Please provide details of your daily	•	Date paid to
work duties	•	Gross amount paid

Is the nature of the work physical or	Is your employer continuing to pay
non physical?	you?
Are alternative duties available to	If yes, when will payment cease?
you? (e.g. light, modified)?

59. Please provide the following details regarding your employer—	employer? If yes, how (eg employer is aunt)?
•	Business name

•	any doctor, ambulance service, hospital or other health service provider
•	an insurer carrying on the business of providing Worker's Compensation insurance or motor vehicle insurance
•	a department, agency or instrumentality of the Commonwealth or the State or another State that administers Police, Health Insurance Commission payments or social welfare laws.