Agreement to Waive Assessment of Impairment

FORM 3

Regulation 7

AGREEMENT TO WAIVE ASSESSMENT OF IMPAIRMENT

Wrongs Act 1958

Section 28LO(1A)

1. CLAIMANT'S NAME

Claimant's full name:

2. CLAIMANT'S DETAILS

Go to Part 3 if the claimant has a legal representative.

Claimant's address:

Claimant's telephone number:

Claimant's email:

Claimant's date of birth:

3. CLAIMANT'S LEGAL REPRESENTATIVE'S DETAILS

Go to Part 4 if the claimant does not have a legal representative.

Legal representative's name:

Legal representative's address:

Legal representative's telephone number:

Legal representative's email:

4. RESPONDENT'S DETAILS

Name of respondent:

Address of respondent:

Telephone number of respondent: [leave blank if not known]

Reason why claimant asserts the respondent is the proper respondent to theclaim:

5. ADDITIONAL RESPONDENTS

For each other party the claimant considers to be a proper respondent:

Name:

Address:

Telephone number: [leave blank if not known]

Reason why claimant asserts this party is the proper respondent to the claim:

6. DESCRIPTION OF THE INCIDENT

Date of incident:

Time of incident:

Location of incident:

Description of incident:

7. THE INJURY TO THE CLAIMANT

Set out all the injuries that you claim you suffered as a result of the incident:

Details of any one or more of the following categories of loss suffered by the claimant as a result of the injury:

(i) Pain and suffering

(ii) Loss of amenity of life

(iii) Loss of enjoyment of life

8. DOCUMENTATION OF THE INCIDENT AND INJURY

If the claimant intends to reply on a report of the incident to make the claim:

Date of report:

Name of person to whom the report was made:

If the claimant has been treated by a medical practitioner in relation to the injury:

Name of medical practitioner:

Professional qualifications of medical practitioner:

Address of medical practitioner:

Telephone number of medical practitioner:

Email of medical practitioner:

9. CERTIFICATION BY CLAIMANT (or claimant's legal representative)

Signature of claimant: Date:

Please note:

Under subsection 28LO(2) of the Wrongs Act 1958, a respondent who has received this Form must respond in writing to the request within 60 days of receiving it.