Notification Form: Transport Accident Act Common Law Time Limit Protocols

Important notes
This form is to be used when an application for a serious injury certificate pursuant to the Common Law Protocols or Supplementary Common Law Protocols will be made out of time and the processes pursuant to the Transport Accident Act Common Law Time Limit Protocols apply.

Please ensure the form meets the criteria outlined in Clauses 5 or 6 and 7 and 8 of the Transport Accident Act Common Law Time Limit Protocols

Client details

Claim number *

Date of accident *

Date of birth *

Client first name *

Client last name *

Clients lawyer

Firm name *

Firm address *

Firm suburb *

Firm postcode *

Practitioner *

Email *

Phone number *

Reference number *

Defendant information

Defendant	Registration Details
Defendant 1	Registration Details 1
Defendant 2	Registration Details 2
Defendant 3	Registration Details 3
Defendant 4	Registration Details 4

Timetable for lodging of a serious injury application in accordance with the Common Law Protocols

Please provide the expected date of lodgment of the serious injury application (including all material required pursuant to Clause 7.2 of the Transport Accident Act Common Law Time Limit Protocols)

Anticipated date of lodgment *

Please note the anticipated date of lodgment must be within 6 months of the date of notification pursuant to Clauses 5.1 and 6.1 of the Transport Accident Act Common Law Time Limit Protocols

Date of Notification *

Lodged by *

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 clients. 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 client’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 w ww.tac.vic.gov.au