Fields on page 1
case or claim reference numbers (if known)
Insurer
No
Yes
Provide Medicare card
card number
1.MCN 3
Ref no.
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Second given name
or call 1800 777 653 Monday to Friday, 8:30 am to 5 pm (local time).
of birth (DD MM YYYY)
(DD MM YYYY)
Postal address
Postal address
If you have a hearing or speech impairment, you can use
Postcode
Fields on page 2
Daytime phone number (including area code)
Mobile phone number
Email
No
Yes
Younger than 14
capacity to act on their own behalf
Deceased
Parent
Guardian
Legal representative
Public trustee
Other
Other
or date of the first the one on the
date of the first treatment. one on the case.
the first treatment. The date of the case.
Provide a brief description of the injury or illness
Compensation payer’s case reference
Compensation payer’s business name
Australian Business
Business Number
Number (ABN)
(ABN)
Postal address
Postal address
1.CP1 PostAdd3
Postcode
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Dr Mr Mrs Miss Ms Mx Other Family name
First given name
Second given name
Contact person’s position (for example, claim manager, compensation assessor)
Daytime phone number (including area code)
Email
Fields on page 3
Solicitor’s or agent’s case reference
Solicitor’s or agent’s business name
Australian Business
Business Number
Number (ABN)
(ABN)
Postal address
Postal address
1.CPA1 PostAdd3
Postcode
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Dr Mr Mrs Miss Ms Mx Other Family name
First given name
Second given name
Contact person’s position (for example, claim manager, compensation assessor)
Daytime phone number (including area code)
Email
No
Yes
Compensation payer’s case reference
Compensation payer’s business name
Australian Business
Business Number
Number (ABN)
(ABN)
Postal address
Postal address
1.CP2 PostAdd3
Postcode
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Dr Mr Mrs Miss Ms Mx Other Family name
First given name
Second given name
Contact person’s position (for example, claim manager, compensation assessor)
Daytime phone number (including area code)
Email
Fields on page 4
Solicitor’s or agent’s case reference
Solicitor’s or agent’s business name
Australian Business
Business Number
Number (ABN)
(ABN)
Postal address
Postal address
1.CPA2 PostAdd3
Postcode
Dr
Mr
Mrs
Miss
Ms
Mx
1.CPA2 SalutOther
Dr Mr Mrs Miss Ms Mx Other Family name
First given name
Second given name
Contact person’s position (for example, claim manager, compensation assessor)
Daytime phone number (including area code)
Email
Injured person’s or claimant’s full name
1.Signature
-
Date of signature
of signature (DD MM
(DD MM YYYY)
