Fields on page 1
case or claim reference numbers (if known)
Injured person is the person in respect of whose injury or illness the
individual (such as a friend, relative or legal representative) who has
card number (if known)
1.MCN 3
1.MCN 4
Dr
Mr
Mrs
Miss
Ms
Mx
Ref no.
Family name
First given name
Second given name
Date of birth (DD
of birth (DD MM YYYY)
(DD MM YYYY)
Fields on page 2
Postal address
Postal address
1.Pat PostAdd3
Postcode
Daytime phone number (including area code)
Mobile phone number
Email
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.
Brief description of the injury or illness
Workers’ compensation
Motor vehicle accident
Common law
Public liability
Other
Other
No
Yes
Medicare
Insurer
Insurer Compensation type
Medicare
Insurer
Insurer Compensation type
No
Yes
Younger than 14
capacity to act on their own behalf
Deceased
Parent
Guardian
Legal representative
Solicitor
Public trustee
Other
Other
Dr
Mr
Mrs
Miss
Ms
Mx
1.Claim SalutOther
Family name or business name (if applicable)
First given name
Second given name
Fields on page 3
Postal address
Postal address
1.Claim PostAdd3
Postcode
Daytime phone number (including area code)
Mobile phone number
Email
No
Yes
Parent
Guardian
Legal representative
Solicitor
Public trustee
Other
Other
Solicitor’s or authorised third party’s case reference
Solicitor’s or authorised third party’s business name
Dr
Mr
Mrs
Miss
Ms
Mx
Other
Family name
First given name
Second given name
Postal address
Postal address
1.ATP PostAdd3
Postcode
Daytime phone number (including area code)
Email
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
1.CP1 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
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.CPA1 PostAdd3
Postcode
Dr
Mr
Mrs
Miss
Ms
Mx
1.CPA1 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
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 5
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
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
Full name
Title (injured person, claimant, injured person’s or claimant’s authorised third party or compensation payer)
1.Signature
SIGN
On On completion, completion, Date of signature
On On completion, completion, insert insert of signature (DD MM
insert insert digital digital signature signature or (DD MM YYYY)
