Important notes In completing this form you are authorising the TAC to pay your loss of earning benefits or loss of earnings capacity benefits directly to your employer. Your employer can then reinstate leave you have taken due to your transport accident injuries. The TAC will make these payments to your employer until: your employer ceases to pay you, or you withdraw this authority to pay your employer.	Privacy The TAC will retain the information provided and may use or disclose it to make further inquiries or assist in the ongoing management of the claim or any claim for common law damages. The TAC may also be required by law to disclose this information. Without this information, the TAC may be unable to determine entitlements or assess whether treatment is reasonable and may not be able to approve further benefits and treatment. If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our website at www.tac.vic.gov.au

Client details

Client name	Claim number

Have you returned to work? Yes No	If ‘Yes’, the date you returned to work	/ /

If ‘No’, is your employer continuing to pay you? Yes No	If ‘Yes’, the date payments will cease?	/ /

Employer details

To assist in processing your claim promptly you may ask your employer or employer’s representative to endorse your answers to the above questions.

Employer name	Telephone number
Employer’s representative name	Employer’s email address
Employer’s address
Signature of employer/employer’s representative
Post code

Employer bank details

For the TAC to reimburse your leave credits to your employer, we require your employer’s bank account details. This will allow the TAC to credit funds directly into your employer’s bank account. The TAC cannot reimburse your leave entitlements by cheque.

Full name of employer	Bank account name
Bank where account is held	Branch where account is held
BSB number (six digits only)	Account number

Authority

I hereby authorise that the TAC pay my loss of income payments as assessed under the Transport Accident Act 1986 to my employer in respect of the paid leave entitlements I have used as a result of the transport accident injury for the purpose of reinstating my employee leave entitlements.

Signature of client, parent or guardian	Print name	Date
/ /