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Notice of Accident Claim Form

Notice of Accident Claim Form

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Notice of Accident Claim Form

Before we can bring a claim for accident compensation on your behalf, we require you to complete our Accident Claim Form below.

Upon receipt of your completed Accident Claim Form one of our team will contact you to discuss your potential claim for compensation. Please note that all questions with an * should be completed.

Medical Certificate

Before we can finalise your Accident Claim Form, you will need to have your general practitioner (doctor) complete a Medical Certificate. The Medical Certificate is available in the Accident Forms download area of our website. Before you see your general practitioner please make a list of all of the areas of your body that are painful and sore as a result of the accident and make sure that your general practitioner specifically refers to each of the painful areas of your body on the medical certificate. The insurer will only pay for the treatment on the areas of your body that are specifically referred to on the Medical Certificate. Please also ensure that your general practitioner includes a referral on the Medical Certificate for physiotherapy, psychological counselling, orthopaedic specialist or any other medical specialist as appropriate.

Claim type
Injured persons details
Have you made an application to the National Injury Insurance Scheme Queensland?
Are you a participant in the National Injury Insurance Scheme Queensland?
Do you have any personal injury, illness or disability (either before or since the accident) that may affect the extent of the disability resulting from the personal injury to which this claim relates or may affect the amount of damages in any other way?

Significant disability means any personal injury, illness, or disability that either;

1) May be relevant to the assessment of the extent of the injury suffered by the injured person in the accident; OR

2) The symptoms lasted for four (4) weeks or more.

Accident details
Type a brief description
Who caused it and why are they to blame?
Acceptable file formats PDFs, bitmap images, word documents and .zip files. If the total file size of your documents exceeds 10mb, please compress them into a zip file first before upload.
Vehicle 1 details
(include unit number (if applicable), street number and street name)
(include unit number (if applicable), street number and street name)
Vehicle 2 details
(include unit number (if applicable), street number and street name)
(include unit number (if applicable), street number and street name)
Other vehicles involved
Vehicle 3 details
(include unit number (if applicable), street number and street name)
(include unit number (if applicable), street number and street name)
Vehicle 4 details
(include unit number (if applicable), street number and street name)
(include unit number (if applicable), street number and street name)
Witness details
Witness 1 details
(include unit number (if applicable), street number and street name)
Additional witnesses
Witness 2 details
(include unit number (if applicable), street number and street name)
Police report
Employment at date of accident
Have you lost or will you lose wages, salary, business or other income because of the accident?
(before tax)
(before tax)
Identification

You must attach a certified copy of an identity document issued by a government which contains a colour photograph of you and which is current. This identity document is required to be certified by a lawyer, notary public, Commissioner for Declarations or a Justice of the Peace.

If you do not hold identification of this type, please attach a colour, passport-sized photograph of yourself taken within the last two years. This photograph should be a full-face view of your head and shoulders and be of good quality. This photograph is required to be certified by a person who has known you for at least one (1) year. They must write on the back or below the photograph: 'This is a true photograph of [your name]' and write their full name, the date and sign the photograph below this statement.

The above identification requirements only apply to claimants who are aged 15 and over.

Acceptable file formats PDFs, bitmap images, word documents and .zip files. If the total file size of your documents exceeds 10mb, please compress them into a zip file first before upload.
Additional information
Once you press the submit button a copy of your online Accident Claim Form will be emailed to your email address and Injury Lawyers Queensland. Once your Accident Claim Form is received one of our team will contact you shortly to discuss your potential claim for personal injuries.

 

Accident Type
Contact Us
Enquiry details

 

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