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Impairment Application Form
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Getting Started

Impairment Application Form
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DISPUTE RESOLUTION APPLICATION: NO FAULT DISPUTE RESOLUTION PROTOCOLS
Important Notes:

This form is to be used by lawyers lodging a Dispute Resolution Application (DR Application) pursuant to the No Fault Dispute Resolution Protocols 2016.

Please complete this form identifying the decision the subject of the DR Application, and provide any information and documents in accordance with Chapters 5 and 10-15 of the No Fault Dispute Resolution Protocols which are already in the possession of the claimant and/or their lawyer and which are to be relied on in the DR.

Enquiries to: iew@tac.vic.gov.au
IMPAIRMENT APPLICATION FORM: IMPAIRMENT ASSESSMENT PROTOCOLS
Important Notes:

This form is to be used by lawyers requesting an impairment assessment on behalf of a claimant 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).

Enquiries to: protocols@tac.vic.gov.au

Claimant Details

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Is the claimant under 18 years of age? *
Does the claimant have any other claims? *
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Is this other claim part of this application? *

Claimant’s Lawyer

Firm Address *

Injuries

Please list the injuries and/or conditions the claimant relates to the subject accident/s.

Supporting documentation

Please list, medical material and relevant treatment information detailing the claimant’s transport accident related injuries (attach where not previously provided)
Attach supporting material
TAC
File:

Impairment Calculator

Enter all impairment scores below to calculate a combined score

Summary and analysis of impairment

Claimant’s lawyer’s suggested whole person impairment percentage based on the current evidence, including reference to the relevant AMA Guides section and any other relevant information

More information

Do you intend on providing any further information? *

Guardian / Administrator

Has the claimant had an administrator appointed? *
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TAC
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Information for Solicitors

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 claimants. The TAC will retain any information provided to the TAC as part of the impairment assessment process, and may use or disclose that information to make further inquiries or assist in the ongoing management of the claimant’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 www.tac.vic.gov.au.