Fillable Application for damages under common law (New South Wales)

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Application for damages under common law (New South Wales)

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The Application for damages under common law (New South Wales) form is 3 pages long and contains:

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  • 4 check-boxes
  • 38 other fields

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Page 1 of 3
Application for damages
under common law
CTP GREEN SLIP CLAIM FORM
Use this form to lodge a common law claim for damages if:
or or
Your whole person
impairment (WPI)
has been conrmed
to be more than
10% as the result
of a motor vehicle
accident
It has been
20 months since
the date of your
accident and you
were not at fault,
not suffering a
minor injury
Your insurer has
advised you to
complete this form
What happens next?
1
The insurer will be in touch with you
The insurer will contact you to discuss your claim and request any
further information or details you have about your claim and the
accident.
2
The insurer will assess your claim
The information you provide will help the insurer assess your claim.
The information requested on this form is required by laws covering
motor accident compensation. If you do not give the required
information, your claim may be rejected or delayed.
3
Damages determination will be made
You must sign the declaration and authority. The declaration
conrms that your statement is true and honest. The authority
provides the insurer access to relevant information to complete
their assessment of the claim. If your claim does not include a signed
declaration and authority page, it may be rejected or delayed.
Checklist
Completed the
Application for personal
injury benets claim form.
Medical certicate
showing your tness
from your GP.
Evidence of income – attach
these if you would like to
claim for lost income.
Keep a copy of this form
and anyattachments such
as evidence of medical
treatment.
What you will need to complete this form
• Complete this form and send it to the insurer or contact our CTP Assist service on 1300 656 919.
• If you’re lling out this form by hand, please use a blue or black pen.
• Mark boxes like this with a or a .
• Any attachments will form part of this claim and the declaration and authorisation will include them. This form is
for accidents on or after 1 December 2017.
• If you need advice about this form please contact CTP Assist on 1300 656 919 or email:
ctpassist@sira.nsw.gov.au
• If you’re acting on behalf of the claimant as a family member or as a personal legal representative, please attach
a page identifying who you are, your relationship to the claimant, and the reason you’re acting on their behalf.
If you need an interpreter, please tell us your preferred language.
Don’t forget to include this page when you submit your claim.
You must ll out the application for personal injury benets form before lling out this form.
Page 2 of 3
Page 2 of 6
1. Your details
Full name
Date of birth (dd/mm/yyyy)
Gender
F M X
/ /
Mobile Email Home phone Work phone
Email address
Home address (unit, street number, street name, suburb, state, postcode)
Mobile phone number Home phone number (if applicable) Work phone number (if applicable)
Contact preference Preferred contact time
Medicare number and reference number Driver licence number (if applicable)
Direct deposit Cheque
Please provide your CTP claim number (if known)
Payment preference and details
Account name BSB Account number
2. Declaration
Please read this declaration carefully before writing your name and signing.
• All information you have provided in this claim form must be true and correct in every respect.
• Under section 307C of the Crimes Act 1900, you can be issued with a ne up to $22,000 or imprisoned for
two years, or both, for knowingly providing false or misleading information in this form.
• The injured person must sign the declaration unless they are under 18 years or are unable to make the
declaration. In this case a parent, guardian, relative or friend of the injured person must sign the declaration.
Claimant’s signature
Date (dd/mm/yyyy)
/ /
I, (print name)
declare that, to the best of my knowledge, the information given by me in this form is true and correct.
I understand that if I knowingly make a false statement on this form that I may be liable for punishment by law.
Please print this page and sign here
Page 3 of 3 Catalogue No. SIRA08744 10/17
The insurer will need authority to collect your personal and health information to help manage your claim.
Insurers may need to disclose personal and health information about you to each other and relevant organisations.
3. About your personal information
Why?
• To ensure the claim is compliant with New South Wales motor accident injury legislation.
• For the purpose of enabling the insurer to process, assess and manage your claim and to verify any
evidence you may submit in support of your claim.
• For the purposes of legal proceedings under that legislation if required.
• To assist with your rehabilitation and to assist the insurer to better manage claims.
Why?
• To process, assess and manage your claim.
• To support any complaint or enquiry made by you to any authority.
• Personal and health information provided by you may be retained, used and disclosed by:
– licensed insurers to manage your claim and determine your entitlements, and
– the State Insurance Regulatory Authority (SIRA) as regulator of the CTP scheme under the Motor Accident
Injuries Act 2017.
• Any personal and health information you provide will be collected, retained, used and disclosed in accordance
with (where relevant) the Privacy and Personal Information Protection Act 1998 (NSW) (PPIP Act), Health
Records and Information Privacy Act 2002 (HRIP Act), Commonwealth Privacy Act 1988, the Motor Accident
Injuries Act 2017 and SIRA’s Privacy Management Plan.
• Under the Motor Accident Injuries Act 2017, SIRA may, despite anything to the contrary in the PPIP Act or the
HRIP Act, collect, use and disclose data relating to third party policies, claims, activities and performance of
insurers and the provision of health, legal and other services to injured persons.
4. Collection of personal and health information to manage
your claim
5. Declaration and authorisation
Please read this declaration carefully before writing your name below and signing.
• All information you have provided in this claim form must be true and correct in every respect.
• Under section 307C of the Crimes Act 1900, you can be issued with a ne up to $22,000 or imprisoned for two
years, or both for knowingly providing false or misleading information in this form.
• You authorise the insurer to contact and obtain information and documents relevant to the claim from persons
specied in this authorisation below and provide information and documents so obtained to persons specied
in this authorisation below.
The consent and authorisation to release, use, disclose and exchange personal and health information on this form
and information obtained in the course of the processing and managing my claim for damages under common law
apply to and between:
• any doctor, ambulance service, hospital or other health related service provider
• any police department
• any property damage insurer
• any employer or accountant of the injured person
• any personal injury insurer or workers compensation insurer
• Centrelink
• Medicare Australia
• Lifetime Care and Support Authority of NSW
• State Insurance Regulatory Authority (SIRA).
Signature
Date (dd/mm/yyyy)
/ /
I, [Name]
declare that, to the best of my knowledge, the information given in this form is true and correct. I also give
consent and authorisation for the collection, use, disclosure and exchange of personal and health information
provided in this form.
Please print this page and sign here.
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Application for damages under common law (New South Wales)

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Completed 22 June 2022

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