Application Form
Application for registration to provide services to clients under the Catastrophic Injuries Support Scheme General Information and Instructions Who should complete this application form? Treatment, care and support providers who are seeking to register with the Insurance Commission of Western Australia (Insurance Commission) under the Catastrophic Injuries Support Scheme (CISS) to provide services to people catastrophically injured in motor vehicle accidents in Western Australia. It is a requirement that a provider be currently registered with the Disability Services Commission of Western Australia (DSC) for the services they seek to register for delivery to Insurance Commission Clients. Treatment, care and support providers who wish to provide services to Insurance Commission Clients must accept the Registration Terms and Conditions. A signed copy of the Terms and Conditions must be attached to this Application for Registration. How to complete This application form must be submitted electronically. Once this application is complete, save as [PROVIDER NAME] CISS Registration. Email the signed and scanned form to mvcisupport@icwa.wa.gov.au along with any supporting documentation. NB: If the email exceeds 20MB, you may need to submit your additional documents in separate emails. Read Before Completing Form Before providing this application form to the Insurance Commission, please complete the following: Consent & Declarations

Criteria

Services for which you wish to be registered

I wish to be registered for the following services:

vocational training or vocational rehabilitation services

Please specify:

Business Details

ABN/CAN	Registered business/company name

Trading name(s) (if applicable)

Registered business address

Business phone

Business email

Business website

Postal address (if different to the above)

Is the business registered for GST?

Contact Details

Title	Given name(s)	Family name

Position

Business phone	Mobile phone

Email

Banking Details

BSB number

Account number

Account name

Provision of Services

Capability and Experience

Please indicate ‘’ against the services you wish to deliver and the number of years of experience working with adults and children in those areas.

Injury Type	Adults	Children
‘’	Years Experience	‘ ’	Years Experience
Spinal Cord Injury
Traumatic Brain Injury
Amputations
Burns
Permanent Blindness

Registration with Disability Services Commission

Are you currently registered with the Disability Services Commission?

If yes, please provide the following details:

DSC identifier

If no, please provide the following details:

Has an application been lodged?

Date that the application was lodged?

/ /

If no are you willing to apply?

Are there any significant events, matters or circumstances that have arisen since your registration with the Disability Services Commission that the Insurance Commission should be aware of?

If yes, please provide details:

Information

Information Release

I authorise the Disability Services Commission to release to the Insurance Commission all information held by the Disability Services Commission in relation to my registration, including contract details, quality assurance and safeguard framework assessments, and any reporting about my business.

NB: This is a compulsory requirement for registration with the Insurance Commission. Failure to provide authorisation for the release of this information may result in your application not being considered.

Disclosure of Information

The provider agrees to the Insurance Commission disclosing any information supplied under, or in connection, with this Application for Registration to any person to enable the Insurance Commission to:

verify any such information; or

meet public disclosure obligations the Insurance Commission may have:

under any current or future legislation;

under any current or future policy of the Insurance Commission or the Government of Western Australia;

in the course of official duties of the Minister responsible for the Insurance Commission;

to satisfy requirements of parliamentary accountability;

under annual reporting obligations of the Insurance Commission; or

to satisfy any other recognised public requirement.

The provider agrees to the disclosure by any person to the Insurance Commission of information concerning the provider or its personnel for the purpose of the Insurance Commission exercising its rights set out in these Registration Terms and Conditions or at law.

Declaration

I declare:

that all information in this Application for Registration is true and correct at the time of application;

that all quality assurance and safeguard frameworks applying to the Disability Services Commission contract that my business has been assessed against, apply to this registration process;

that any relationship to an Insurance Commission client or officer will be disclosed;

that I will comply with all relevant legislation and codes in the provision of the services to clients; and

that I will comply with the Registration Terms and Conditions as set out on the Insurance Commission of Western Australia’s website which may be amended from time to time.

Business / Company name

Name of authorised representative

Signature of authorised representative	Date

/ /

Position held by authorised representative