Forms

To start receiving defined benefits for your own injuries, please complete and submit the Personal Injuries Application and MAI Medical Report (completed by your doctor) to the MAI insurer of the most at fault vehicle.

• Personal Injuries Application 435 KB
• MAI Medical Report 291 KB

For ongoing income replacement benefits, a MAI Fitness For Work Certificate is required to be completed by a medical practitioner. You will need to give this form to your medical practitioner for the certificate, and to provide your own work declaration.

• MAI Fitness For Work Certificate 277 KB

A Quality of Life Benefit Application is available if you have an injury or injuries of a permanent nature as a result of your motor accident and it has been more than 6 months from the date of your motor accident.

• Quality of Life Benefit Application 317 KB

If you have a family member who died as a result of a motor accident, you can use the following forms to apply for funeral benefits and dependent benefits.

• Funeral Benefits Application 391 KB
• Dependent Benefits Application 434 KB

Common law compensation under the Motor Accident Injuries scheme will only be available for people who were injured by someone else’s negligence in the accident and meet at least one threshold category:

• have a whole person impairment of at least 10 per cent, or
• is a child still receiving treatment and care benefits four years and six months after the accident, or
• is an adult still receiving income replacement benefits four years and six months after the accident and is assessed with a significant occupational impact.

In the case of a blameless accident, such as where the driver has a heart attack or a kangaroo hops onto the road, the driver may be said to be at-fault (or deemed at-fault), to allow for other persons injured in the accident to make a common law claim.

A common law claim can be made for:

• reasonable and necessary treatment and domestic care (paid care only) for as long as the person is likely to need it.
• income replacement for as long as the person is likely to need it. The first 12 months is limited to the amount available under the defined benefits. After 12 months, 100 per cent of loss of earning capacity plus superannuation can be claimed. A maximum pre-injury weekly earnings amount of $4,500 applies.
• loss of quality of life compensation, up to a maximum of $600,000, based on the whole person impairment (WPI) scale and any impacts the Court considers were not taken into account as part of the WPI assessment (such as a particular effect on the person’s quality of life). This does not apply to children - the court will determine the amount payable for a child.
• death benefits (funeral costs plus compensation for dependants).

A common law damages award will take into account any benefits already received under the scheme.

A common law award is paid as a lump sum.

Complete the notice of claim form (if applicable) 271.2 KB

The email addresses below are for ACT licensed MAI insurers:

For accidents where the at fault vehicle is unregistered or uninsured or otherwise unable to be identified (eg. a hit and run) or is subject to an unregistered vehicle permit, the application for defined benefits may be sent to the Nominal Defendant.

Email: nominaldefendant@act.gov.au
Phone: (02) 6207 0184 (9:00am – 5pm, Mon-Fri)

The Nominal Defendant will only accept an application for a most at fault unidentified vehicle once you have undertaken reasonable steps to inquire into and search for the most at fault vehicle.