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Table 4.1: Application for personal injury benefits

Form field

Form field

Form field

Full name

Date of birth

Gender

Interpreter language

Medicare number and reference number

Driver licence number

Mobile phone number

Home phone number

Work phone number

Email address

Home address

Contact preference

Preferred contact time

Payment preference and details

Account name

BSB

Account number

Have you ever made a CTP claim for injury

Date of injury

Claim number

CTP insurer at time of injury

Please provide your police event number

Date of the accident

Approximate time of accident

Where did the accident occur

In the accident, were you the

In your own words, please describe (or draw) the motor vehicle accident you were involved in

In your own words, please outline all injuries you received as a result of the accident you have described above

Details of all vehicles involved in the accident

What is the registration number of the car you believe to be most at fault

Did you receive treatment at hospital after the accident

Name of the hospital where you were treated

Were you taken to hospital in an ambulance

Have you been discharged from hospital

Date of discharge

Were you suffering an illness or injury affecting the same or similar parts of your body at the time of the accident

Have you been away from work as a result of the accident

Length of time off work due to the accident

What was your employment status at the time of the accident

What is your usual occupation

Please outline your earnings at the time of the accident (Please circle whichever time frame applies)

Please provide your/your employer’s company name

Were you receiving Centrelink benefits at the time of the accident

Would you like us to obtain your wages information directly from your employer

Employer contact name

Email address

Mobile phone number

Contact address (unit, street number, street name, suburb, state, postcode)

I, (print name)

Claimant's declaration, authorisation  and signature

Date