Western Australian Current Regulations

MOTOR VEHICLE (THIRD PARTY INSURANCE) REGULATIONS 2009 - SCHEDULE 1

[r. 5(1)]

Form

Motor Vehicle (Third Party Insurance) Act 1943					Official use Ref. No. ..............
NOTICE OF INTENTION TO MAKE CLAIM
I notify the Insurance Commission of Western Australia that ...................................... ............................. [name of claimant] intends to claim damages for death/bodily injury directly caused by, or by the driving of, a motor vehicle.
Details of crash
Date	........./........./.........		Registration Number of vehicle involved (if known)		................................
Name and address of driver		Surname		Given Names
		Address
Circumstances of crash
Name and address of each witness		Surname		Given Names
		Address
Details of deceased or injured person
Name and address		Surname		Given Names
		Address
Date of birth		.........../.........../...........
Relationship to claimant (if applicable)
Occupation and employment details
Nature of known injuries
Name and address of each doctor/hospital attended
Details of previous claims
Has the claimant previously made a personal injuries claim in respect of this or any other injury?         Yes         ?         No         ? If yes, provide the following details in respect of each claim.
Date of injury
Details of injury
Type of claim (e.g. work, home, sports, motor vehicle)

Date

Signature

Notes

This is a compilation of the Motor Vehicle (Third Party Insurance) Regulations 2009 and includes amendments made by other written laws. For provisions that have come into operation see the compilation table.

Compilation table

Citation	Published	Commencement
Motor Vehicle (Third Party Insurance) Regulations 2009	26 Jun 2009 p. 2570‑3	r. 1 and 2: 26 Jun 2009 (see r. 2(a)); Regulations other than r. 1 and 2: 27 Jun 2009 (see r. 2(b))
Motor Vehicle (Third Party Insurance) Amendment Regulations 2014	8 Jan 2015 p. 111‑12	r. 1 and 2: 8 Jan 2015 (see r. 2(a)); Regulations other than r. 1 and 2: 27 Apr 2015 (see r. 2(b) and Gazette 17 Apr 2015 p. 1371)
Treasurer Regulations Amendment (Workers Compensation) Regulations 2024 Pt. 3	SL 2024/133 26 Jun 2024	1 Jul 2024 (see r. 2(b))

Defined terms

[This is a list of terms defined and the provisions where they are defined. The list is not part of the law.]

Defined term         Provision(s)
managing director         3

© State of Western Australia 2024.
This work is licensed under a Creative Commons Attribution 4.0 International Licence (CC BY 4.0). To view relevant information and for a link to a copy of the licence, visit www.legislation.wa.gov.au .
Attribute work as: © State of Western Australia 2024.

By Authority: GEOFF O. LAWN, Government Printer