report catastrophic injury form

Forms

Initial Report of a Catastrophic Injury

You must report a motor vehicle crash using the Online Crash Report Form soon after the crash.

You can also notify the Insurance Commission of a catastrophic injury (traumatic brain injury, spinal cord injury, amputation(s), permanent blindness, or severe burns) by completing the form below. Alternatively you can contact the Insurance Commission on +61 (8) 9264 3333.


Required fields are marked with an asterisk ( * )

Crash details

Was a catastrophic injury sustained as a result of a motor vehicle crash? *
Date of crash *

Injury and Hospitals

Injury type *
*


Personal details - Injured Party

*
*
*
Date of birth *

Address - Injured Party

Street







Contact details - Reporting Party

*
*


*




Supporting documentation

File formats accepted: jpg, gif, tiff, pdf, doc, docx, xls, xlsx

Upload limit 4MB per file

Hospitals and Medical professionals are also able to provide further detailed information in relation to sustained catastrophic injuries. In order to do so please download and complete the attached Notification of Catastrophic Injury Form and contact the Care Services Team on +61 (8) 9264 3333


Non-catastrophic injuries from crashes are only required to be reported via the Online Crash Report Form. If you wish to speak to the Insurance Commission please call +61 (8) 9264 3333.

Catastrophic injury (traumatic brain injury, spinal cord injury,
amputation(s), permanent blindness, or severe burns) sustained from a motor vehicle accident in Western Australia from 1 July 2016.

You can provide further information in relation to the injuries that have been sustained in this comments box. Alternatively you can provide this information through the "Supporting Documentation" option at the end of this form.

Page Last Updated 06 Dec 2018