Transport Accident (Amendment) Regulations 2000 (Vic)

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Transport Accident (Amendment) Regulations 2000

S.R. No. 106/2000

TABLE OF PROVISIONS

Regulation Page

1. Objective 1
2. Authorising provision 1
3. Principal Regulations 1
4. Claim for compensation form 1

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ENDNOTES 9

i

STATUTORY RULES 2000

S.R. No. 106/2000

Transport Accident Act 1986

Transport Accident (Amendment) Regulations 2000

The Governor in Council makes the following Regulations:
Dated: 17 October 2000
Responsible Minister:
BOB CAMERON
Minister for WorkCover

HELEN DOYE

Clerk of the Executive Council

1. Objective
The objective of these Regulations is to prescribe the claim for compensation form 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. Principal Regulations
In these Regulations the Transport Accident
Regulations 19961 are called the Principal
Regulations.

4. Claim for compensation form
For Form 5 in the Schedule to the Principal
Regulations substitute—

Transport Accident (Amendment) Regulations 2000

S.R. No. 106/2000 r. 4

'FORM 5

CLAIM FOR COMPENSATION UNDER THE TRANSPORT

ACCIDENT ACT 1986

PERSONAL DETAILS
1. Surname
Title

Given names Male/Female Home phone Work phone Mobile phone (if applicable)

Date of Birth

E-Mail Address (if applicable)
Address
Fax number (if applicable)

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 this transport accident? If yes, please provide details below—

Full Name Address Date of Birth Relationship e.g. Have

sister, parent, they
spouse, brother, made a
child, other claim?

3. Do you need an interpreter? TRANSPORT ACCIDENT DETAILS
No (go to 4)

6. Did Police attend the scene of the

Yes—Language spoken accident?
No (go to 7)
4. Have you received or applied for Social

Security or Centrelink payments— Yes—Police Officer's Name

!! because of this transport accident? Stationed at

!! in the six months before this 7. I reported the accident to the Police on

accident? If yes, what type of benefit?

(date) to (Police Officer's name), stationed
at (name of Police Station)

Centrelink/Social Security Reference No. Station book number

5. The TAC pays benefits by direct deposit 8. Provide the following details—
into a bank account of your choice. Please !! Date of accident
provide details of the account into which
you want your benefits paid. !! Day of week
!! Accident time am/pm

!! Name in which the account is held

!! Where did this accident happen?

!! BSB number (6 digits in total)

!! Please describe in your own words

!! Account number (up to 10 digits)
how this accident happened

!! Bank name

!! Please draw a diagram showing how

!! Branch this accident happened
!! Address

Transport Accident (Amendment) Regulations 2000

S.R. No. 106/2000

9.

In this accident, were you a—

16.

Were you the owner of the vehicle you were driving?

!! Driver (go to 10)
Yes (go 17)

!! Car or truck passenger (go to 10)

If no, did you have permission to use the

!! Motorcyclist (go to 10) 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 has

!! Cyclist (go to 18) been held
!! Pedestrian (go to 19)
18. Were you wearing a seatbelt or helmet?

!! Other (go to 18)
19. Is Police action going to be taken in

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

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

20. Had you consumed any alcohol in the two

12. Were you involved in a collision with a hours before this accident?
fixed object?
No (to 21)

13. What was the speed limit at the accident If yes, type and amount consumed
location?
21. Was a breath or blood test undertaken? No (go to 22)

14. Were you the driver of the vehicle?
Yes (go to 15)
If yes, what was your reading?

If no, provide the following details—

!! Driver's surname 22. Had you consumed any drugs (including
medication) in the two hours before this

!! Driver's given names accident?
!! Driver's address No (go to 23)
!! Home phone If yes, type and amount consumed

!! Work phone 23. Did this accident happen on the way to or
!! Mobile phone from work?

15. Provide details of the vehicle you were travelling in—

24. Did this accident happen in the course of your employment?

!! Vehicle registration number 25. Were you taking part in, or in a test in

!! Was the vehicle registered in preparation for, a motor vehicle race or
Victoria: If no, what State was the speed trial?
vehicle registered in?
!! Are you the owner of the vehicle?
!! Make and model of vehicle
(e.g. Holden Gemini)
!! Name of company if train/tram
involved
(All passengers go to 18)

Transport Accident (Amendment) Regulations 2000

S.R. No. 106/2000 r. 4

26. Was any other vehicle involved in the 33. Are you still receiving or expect to receive

accident? treatment for your transport accident
No (go to 27) injuries?
If yes, provide the following details— No (go to 35)
!! Other driver's surname If yes, please provide details of the doctor
who is treating your injuries—

!! Other driver's given names

!! Other driver's address !! Doctor's name
!! Doctor's address

!! Home phone
!! Doctor's telephone number

!! Work phone
!!

Mobile phone 34. Is this your usual doctor?
!!

Registration number Yes (go to 35)
!!

Was the vehicle registered in If no, please provide your usual doctor's
Victoria? If no, what State was the details—
vehicle registered in? !! Doctor's name
!!

Make and model of vehicle !! Doctor's address
(e.g. Holden Gemini)
!! Doctor's telephone number

!! Name of company if train/tram

involved (e.g. Bayside Trains)

35.

Has this transport accident affected any injury or condition you had before the

27. Were there any witnesses to this accident? accident?
No (go to 28)
No (go to 36)

If yes, please provide details—

If yes, please provide details of the injury

!! Witness's surname or condition and the treatment and

!! Witness's given names medication you were taking before the
accident

!! Witness's address
!!

Home phone 36. Before this accident, have you ever
!!

Work phone required treatment—

!! by a chiropractor or physiotherapist?

!! Mobile phone

!! by a psychologist or psychiatrist?

28. Were you transported by ambulance from the scene of this accident?

!! involving orthopaedic or spinal
surgery?

29. Were you taken to hospital?

!! involving hospitalisation in the last

No (go to 30) 5 years?

If yes, provide details below— !! causing more than 4 weeks off work

!! Hospital Name for a medical condition?

!! Was it a visit to the casualty 37. Before this accident, have you ever

Department only? suffered from any of the following

!! Date admitted conditions or problems?
!! Have you been discharged from

!! Lower back condition or pain

hospital? If yes, date discharged

!! Neck condition or pain

!! Head injury or neurological condition

30. List all your injuries from this transport !! Vascular condition

accident. !! Psychological or psychiatric treatment

31. Did you sustain an injury to the head? or condition

!! Hip, knee or shoulder condition or

32. Did you lose consciousness?
pain

No (go to 33)

Transport Accident (Amendment) Regulations 2000

r. 4	S.R. No. 106/2000

Don't know (go to 33) !! Drug dependency (specify drug)
If yes, for how long? (hours/minutes) !! Developmental or cognitive problems
!! Arthritis
!! Orthopaedic or spinal injury

!! Work related injury OCCUPATION OR EMPLOYMENT
!! Epilepsy DETAILS

!! Migraine or similar episodic headache 42. What was your occupation at the time of

!! Asthma this accident?
Are you an employee or self-employed?
!! Heart condition

!! Diabetes 43. Please provide details of all persons who
are wholly or partly dependent on you—

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

No (go to 39) !! Date of birth
If yes, please provide details of the injury !! Relationship to you
or condition and the treatment and

!! Address (if not normally resident with

medication you were taking before this you)

accident !! Is this person a full time student?

39. Before this accident, did you have home service, gardening or child minding

Unemployed details

assistance? 44. Did your injuries prevent you from

No (go to 40) looking for work?
If yes, type of service and number of No (go to 63)
hours per week If yes, how long? (weeks).

40. Have you ever had a Workers Are your injuries still preventing you from

Compensation Claim? looking for work?

No (go to 41) 45. Did you work during the two years before

If yes, provide the following details— this accident?
!! Number of previous claims No (go to 46)
In relation to your most recent claim, If yes, provide the following details—
provide the following details— !! Employer's name
!! Claim number !! Date employed from

!! Date of injury or incident !! Date employed to

!! Injuries sustained 46. At the time of this accident had you
!! Insurance company/employer received an offer of employment?
!! Settlement date No (go to 61)
Are you currently receiving WorkCover or If yes, provide the following details—
other workers compensation benefits? !! Employer's name

41. Have you ever had a Personal Injury !! Employer's address
Claim? !! Employer's phone
No (go to 42) !! Scheduled employment start date
If yes, provide the following details— Have you started this employment?
!! Number of previous claims If yes, date started
In relation to your most recent claim, If no, reason for not starting
provide the following details—

Transport Accident (Amendment) Regulations 2000

S.R. No. 106/2000 r. 4

!! Claim number

!! Date of injury or incident
!! Injuries sustained
!! Insurance company or employer
!! Settlement date

Employment Details

53.

Please provide details of your accountant or the person to contact regarding your

47. Have you had time off work because of your transport accident injuries?

financial records—
!! Name
No (go to 63)

If yes, have you been absent or do you !! Address
expect to be absent from work for more !! Phone number

than 5 days? Employee Details
No (go to 63)
If yes, provide details of the first five days 54. Please provide the following details

of absence or expected absence. regarding your employment—
Have you returned to work? If yes, what !! Employee number
date did you return? If no, what is your !! Date employment commenced
expected date of return (if known)? !! Basis of employment (permanent,

Self-Employed details temporary, casual, seasonal)

Are you employed on a contractual basis

48. Please provide the following details— for a set period? If yes, period of contract?

!! Type of business Are you an apprentice or trainee? If yes,
!! Business name and address provide the following details—

!! Australian Business Number (ABN) What is the status of the business (e.g.

!! Type of apprenticeship or traineeship
!! Date commenced
sole trader, partnership, trust, company)? !! Expected completion date

49. Estimate the loss suffered by the business as a result of this accident

Please provide details of your daily work
duties

Has the business ceased completely since Is the nature of the work physical or non-
this accident? physical?

50. Have you lodged any taxation returns for Are alternative duties available to you?

the last 3 financial years? (e.g. light, modified)?

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

55. Please provide details of your working
week—

!! Which days do you work?

If yes, please provide a separate statement

detailing— !! Average hours per day

!! Name and address of person !! Starting and finishing times
employed
56. Have any amounts been paid to you by

!! Nature of duties performed your employer in respect of your absence
!! Period of each employment from work?

!! Gross and net wages paid each week No (go to 57)
!! Method of taxation deductions made If yes, please provide the following
(i.e. group tax, withholding tax) details—

!! Documentary evidence of payment !! Nature of payment (e.g. sick leave,

such as cheque butts, bank statements annual leave)
etc.

Transport Accident (Amendment) Regulations 2000

r. 4

r. 4	S.R. No. 106/2000

!! Date paid from

52. Please provide details of other income

derived from personal exertion !! Date paid to

!! Gross amount paid
Is your employer continuing to pay you?

If yes, when will payment cease?

On the day of the accident were you on 57. Is regular overtime a condition of your

any type of leave from work or were you employment?
due to commence leave within 4 weeks No (go to 58)
from the date of your accident?
If yes, how much overtime do you work
No on average each week?
Yes

Hours minutes
If yes please specify the type of leave
(e.g. sick leave, annual leave, maternity
leave or unpaid leave).
58. Please provide details of your weekly wage over the 6-week period immediately before this accident

Gross Hourly Allowance No. of No. of

Week normal rate of pay Shift Other type hours days

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

59. Please provide the following details 60. Does your employer have a person to

regarding your employer— assist you to return to work?
!! Business name If yes, please provide the following
!! Address details—

!! Phone number

!! Contact name !! Phone number
!! Nature of business

61. In order to ensure that you are taxed at the

!! Is the number of employees on the

payroll more than 5? appropriate rate, please provide your tax
file number
!! Are you related to your employer?

If yes, how (e.g. employer is aunt)?

62. Are you liable for a HECS debt as a result of tertiary studies?
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. AUTHORITY TO RELEASE INFORMATION
This authority allows the Transport Accident Commission to obtain records or information, which may affect your claim.

Transport Accident (Amendment) Regulations 2000

S.R. No. 106/2000 r. 4

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 affected 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.
STATUTORY DECLARATION
I declare that the information provided in this claim for compensation is true and correct, and I make this declaration 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
Address
Relationship to claimant
Signature
Reason why the claimant cannot sign.'.

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Transport Accident (Amendment) Regulations 2000

Endnotes

S.R. No. 106/2000

ENDNOTES

1 Reg. 3: S.R. No. 164/1996 as amended by S.R. No. 64/1999.

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1.	Objective	1
2.	Authorising provision	1
3.	Principal Regulations	1
4.	Claim for compensation form	1

5.	The TAC pays benefits by direct deposit	8.	Provide the following details—
into a bank account of your choice. Please	!! Date of accident
provide details of the account into which
you want your benefits paid.	!! Day of week !! Accident time am/pm

!!	Motorcyclist (go to 10)	vehicle?
!!	Pillion passenger (go to 10)

10. What was your position in the vehicle immediately before this accident?	relation to the accident?
No (go to 20)
11. If travelling in a car, were you thrown out	If yes, name of person charged

!! Driver's surname	22. Had you consumed any drugs (including medication) in the two hours before this
!! Driver's given names	accident?
!! Driver's address	No (go to 23)
!! Home phone	If yes, type and amount consumed

!! Work phone	23.	Did this accident happen on the way to or
!! Mobile phone	from work?

!! Vehicle registration number	25.	Were you taking part in, or in a test in
!!	Was the vehicle registered in	preparation for, a motor vehicle race or
Victoria: If no, what State was the	speed trial?
vehicle registered in?
!!	Are you the owner of the vehicle?
!!	Make and model of vehicle (e.g. Holden Gemini)
!!	Name of company if train/tram involved

26. Was any other vehicle involved in the	33. Are you still receiving or expect to receive
accident?	treatment for your transport accident
No (go to 27)	injuries?
If yes, provide the following details—	No (go to 35)
!! Other driver's surname	If yes, please provide details of the doctor who is treating your injuries—
!!	Other driver's given names
!! Other driver's address	!! Doctor's name !! Doctor's address
!!	Home phone

If yes, provide details below—	!!	causing more than 4 weeks off work
!!	Hospital Name	for a medical condition?
!!	Was it a visit to the casualty	37. Before this accident, have you ever

Don't know (go to 33)	!! Drug dependency (specify drug)
If yes, for how long? (hours/minutes)	!! Developmental or cognitive problems !! Arthritis
!! Orthopaedic or spinal injury
!! Work related injury	OCCUPATION OR EMPLOYMENT
!! Epilepsy	DETAILS

!! Asthma	this accident? Are you an employee or self-employed?
!! Heart condition
!! Diabetes	43. Please provide details of all persons who are wholly or partly dependent on you—
38. Did you answer "yes" to any part of	!! Full name

39. Before this accident, did you have home service, gardening or child minding	Unemployed details
assistance?	44. Did your injuries prevent you from
No (go to 40)	looking for work?
If yes, type of service and number of	No (go to 63)
hours per week	If yes, how long? (weeks).
40. Have you ever had a Workers	Are your injuries still preventing you from
Compensation Claim?	looking for work?
No (go to 41)	45. Did you work during the two years before
If yes, provide the following details—	this accident?
!! Number of previous claims	No (go to 46)
In relation to your most recent claim,	If yes, provide the following details—
provide the following details—	!! Employer's name
!! Claim number	!! Date employed from

!!	Date of injury or incident	!! Date employed to
!! Injuries sustained	46.	At the time of this accident had you
!! Insurance company/employer	received an offer of employment?
!! Settlement date	No (go to 61)
Are you currently receiving WorkCover or	If yes, provide the following details—
other workers compensation benefits?	!! Employer's name
41.	Have you ever had a Personal Injury	!! Employer's address
Claim?	!! Employer's phone
No (go to 42)	!! Scheduled employment start date
If yes, provide the following details—	Have you started this employment?
!! Number of previous claims	If yes, date started
In relation to your most recent claim,	If no, reason for not starting
provide the following details—

Employment Details	53.	Please provide details of your accountant or the person to contact regarding your
47. Have you had time off work because of your transport accident injuries?	financial records—
!! Name

If yes, have you been absent or do you	!! Address
expect to be absent from work for more	!! Phone number
than 5 days?	Employee Details
No (go to 63)
If yes, provide details of the first five days	54. Please provide the following details
of absence or expected absence.	regarding your employment—
Have you returned to work? If yes, what	!! Employee number
date did you return? If no, what is your	!! Date employment commenced
expected date of return (if known)?	!! Basis of employment (permanent,
Self-Employed details	temporary, casual, seasonal)

!!	Name and address of person	!! Starting and finishing times
employed

!! Nature of duties performed	your employer in respect of your absence
!! Period of each employment	from work?

!!	Gross and net wages paid each week	No (go to 57)
!!	Method of taxation deductions made	If yes, please provide the following
(i.e. group tax, withholding tax)	details—
!! Documentary evidence of payment	!!	Nature of payment (e.g. sick leave,

59. Please provide the following details	60. Does your employer have a person to
regarding your employer—	assist you to return to work?
!! Business name	If yes, please provide the following
!! Address	details—
!! Phone number	!! Contact name !! Phone number
!! Nature of business

!!	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.