Client rep Authority to release information form - TAC

This form allows you to nominate another person to act on your behalf about your TAC claim, and discuss your TAC claim with TAC employees.

We treat your personal information in confidence and in line with the TAC privacy policy.

Please note: We will never ask you to disclose passwords or transfer funds into an unknown bank account. Please contact us if you have any concerns.

1. Personal details

First Name *

Last name *

TAC claim number *

Address *

Suburb *

Postcode *

Date of birth (dd/mm/yyyy) * Day Month Year Day Month Year

Date of accident (dd/mm/yyyy) * Day Month Year Day Month Year

2. Representative’s details

Representative's last name *

Representative's first name *

Representative's phone number *

Representative's address *

Representative's suburb *

Representative's postcode *

Representative’s relationship to you *

if other please specify

3. Your consent

I give permission for the person(s) nominated in this form to:

Act on my behalf about my TAC claim, and
Discuss my TAC claim with TAC employees.

This consent includes:

receiving all correspondence on my behalf, and
making decisions about my TAC claim, such as requesting treatment and services, and
requesting personal and health information about me, and
changing my personal details, including my contact details and bank account details.

Please sign in the box below (using a mouse, your finger or a stylus on a touchscreen)

Clear signature

Client Name *

Date (dd/mm/yyyy) Day Month Year Day Month Year

Important information

Your 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.
If you require further information about our privacy policy, please call the TAC on 1300 654 329 or visit our website at tac.vic.gov.au