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Serious Injury Application Form
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Serious Injury Application Form
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Getting Started

Serious Injury Application Form
Fields marked with * are required
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
Important Notes:

This form is to be used by lawyers requesting a serious injury certificate on behalf of a claimant under Part 6 of the Transport Accident Act 1986 (TAA) and pursuant to the Common Law 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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Claimant’s Lawyer

Firm Address *

Serious Injury Claim Information

Please provide name(s) of all parties against whom a Common Law claim is proposed with registration details of vehicles (if known)

List the injuries relied on by the claimant and the relevant sub paragraphs of the definition of serious injury in Section 93(17) of the TAA

Sub- paragraph of Section 93 (17) *
If liability is admitted, do you intend to bypass impairment?
Is the claim limited to non-pecuniary loss only? *


Has an Affidavit been sworn? *
Attach Affidavit

Supporting documentation

Please provide the following list of documents relied upon in the application (where appropriate) and attach copies where not previously provided to the TAC.
Supporting documentation

More information

Do you intend on providing any further information? *

Other comments

Guardian / Administrator

Has the claimant had an administrator appointed? *
Attach supporting material

Workers compensation claim details

Does the claimant have an accepted WorkCover claim for this accident?

Reasons why the subject accident meets the definition of a transport accident

Details of the claimed negligent vehicle (if known)

WorkCover lodgement

Has a serious injury application been lodged or is intended to be lodged with WorkCover? *

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 serious injury/common law 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.