8 Copy of certificate of assessment to be served on respondent 3
9 Respondent must provide information to Medical Panel 5
Schedule 1—Forms 6
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Endnotes 18
1 General information 18
2 Table of Amendments 20
3 Explanatory details 21
Version No.001
Wrongs (Part VBA Claims) Regulations 2025
S.R. No. 18/2025
Version as at
4 May 2025
1 Objective
The objective of these Regulations is to prescribe forms and other matters for the purposes of Part VBA of the Wrongs Act 1958.
2 Authorising provision
These Regulations are made under section 28LZP of the Wrongs Act 1958.
3 Commencement
These Regulations come into operation on 4 May 2025.
4 Revocation
The Wrongs (Part VBA Claims) Regulations 2015[1] and the Wrongs (Part VBA Claims) Amendment Regulations 2016[2] are revoked.
5 Certificate of assessment
For the purposes of section 28LN of the Wrongs Act 1958, the form of a certificate of assessment is the form set out in Form 1 in Schedule 1.
6 Certificate where injury not stabilised
For the purposes of section 28LNA of the Wrongs Act 1958, the form of a certificate of assessment where an injury has not stabilised is the form set out in Form 2 in Schedule 1.
7 Agreement to waive assessment of impairment
(1) For the purposes of section 28LO(1A) of the , the following information is prescribed—
Wrongs Act 1958
(a) the name of the claimant;
(b) the name of the claimant's legal representative (if applicable);
(c) the address of the claimant or the claimant's legal representative (as the case requires);
(d) the telephone number of the claimant or the claimant's legal representative (as the case requires);
(e) the email address of the claimant or the claimant's legal representative (as the case requires);
(f) the date of birth of the claimant;
(g) the name of the respondent;
(h) the address of the respondent;
(i) the telephone number of the respondent (if known);
(j) a statement of reasons explaining why the claimant asserts that the respondent is the proper respondent to the claim;
(k) the name, address and telephone number (if the number is known) of any party (other than the respondent) who the claimant considers to be a proper respondent to the claim and reasons why the other party is also considered to be a proper respondent;
(l) the date, time and location of the incident;
(m) a description of the incident;
(n) details of the injury suffered as a result of the incident;
(o) details of the non-economic loss suffered by the claimant as a result of the injury;
(p) details of any report of the incident on which the claimant intends to rely, including the date of the report and the person to whom the report was made;
(q) the name, professional qualifications, address, telephone number and email address of any medical practitioner who has treated the injury of the claimant.
(2) For the purposes of section 28LO(1A) of the Wrongs Act 1958, the prescribed form is Form 3 in Schedule 1.
8 Copy of certificate of assessment to be served on respondent
(1) For the purposes of section 28LT(2) of the Wrongs Act 1958, the following information is prescribed—
(a) the name of the claimant;
(b) the name of the claimant's legal representative (if applicable);
(c) the address of the claimant or the claimant's legal representative (as the case requires);
(d) the telephone number of the claimant or the claimant's legal representative (as the case requires);
(e) the email address of the claimant or the claimant's legal representative (as the case requires);
(f) the date of birth of the claimant;
(g) the name of the respondent;
(h) the address of the respondent;
(i) the telephone number of the respondent (if known);
(j) a statement of reasons explaining why the claimant asserts that the respondent is the proper respondent to the claim;
(k) the name, address and telephone number (if the number is known) of any party (other than the respondent) who the claimant considers to be a proper respondent to the claim and reasons why the other party is also considered to be a proper respondent;
(l) the date, time and location of the incident;
(m) a description of the incident;
(n) details of the injury suffered as a result of the incident;
(o) details of the non-economic loss suffered by the claimant as a result of the injury;
(p) details of any report of the incident on which the claimant intends to rely, including the date of the report and the person to whom the report was made;
(q) the name, professional qualifications, address, telephone number and email address of any medical practitioner who has treated the injury of the claimant.
(2) For the purposes of section 28LT(2) of the Wrongs Act 1958, the prescribed form is Form 4 in Schedule 1.
9 Respondent must provide information to Medical Panel
(1) For the purposes of section 28LZA(1)(a)(ii) of the Wrongs Act 1958, the following information is prescribed—
(a) the name of the respondent;
(b) the address of the respondent;
(c) the telephone number of the respondent;
(d) the email address of the respondent;
(e) the date on which the respondent received the claimant's certificate of assessment;
(f) the name, address, telephone number and email address of the respondent's legal or other representative (if any);
(g) the claimant's statement of claim (if this has been provided to the respondent);
(h) a copy of Form 4 received from the claimant.
(2) For the purposes of section 28LZA(1)(a) of the Wrongs Act 1958, the prescribed form is Form 5 in Schedule 1.
Schedule 1—Forms
Form 1
Regulation 5
CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT ARISING FROM STABILISED INJURY
Wrongs Act 1958
Section 28LN
DETAILS OF MEDICAL PRACTITIONER
Name:
Qualification:
Address:
Telephone:
Email:
CERTIFICATION
I certify that on: [date] I examined: [insert name of person seeking the assessment]
of: [address of person seeking the assessment]
and I am satisfied/I am not satisfied [delete whichever inapplicable] that:
[*tick appropriate box/boxes]
*🞏 the degree of impairment resulting from this person's injury (other than psychiatric injury) satisfies the threshold level.
Brief description of injury assessed:
*🞏 the degree of impairment resulting from this person's psychiatric injury and symptoms (which has not arisen as a consequence of, or secondary to, a physical injury) satisfies the threshold level.
Brief description of psychiatric injury assessed:
SIGNED: DATED:
Please note:
This certificate must be provided by a medical practitioner who is an approved medical practitioner within the meaning of section 28LB of the Wrongs Act 1958.
This certificate must not state the specific degree of impairment.
Impairment is defined in section 28LB of the Wrongs Act 1958 to mean permanent impairment.
Threshold level is defined in section 28LB of the Wrongs Act 1958 to mean—
(a) in the case of injury (other than psychiatric injury or spinal injury), impairment of more than 5 per cent;
(b) in the case of psychiatric injury, impairment of 10 per cent or more;
(c) in the case of spinal injury, impairment of 5 per cent or more.
The degree of psychiatric impairment must not have regard to any psychiatric or psychological injury, impairment or symptoms which has arisen as a consequence of, or secondary to, a physical injury—see section 28LJ of the Wrongs Act 1958.
Form 2
Regulation 6
CERTIFICATE OF ASSESSMENT OF DEGREE OF IMPAIRMENT WHERE INJURY HAS NOT STABILISED
Wrongs Act 1958
Section 28LNA
DETAILS OF MEDICAL PRACTITIONER
Name:
Qualification:
Address:
Telephone:
Email:
CERTIFICATION
I certify that on: [date] I first examined: [insert name of person seeking the assessment]
of: [address of person seeking the assessment]
in relation to [*tick appropriate box/boxes]
*🞏 an injury (other than psychiatric injury).
Brief description of injury assessed:
I certify that I have conducted a subsequent examination today in relation to the same injury and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this injury (other than psychiatric injury) will satisfy the threshold level once the injury has stabilised.
*🞏 a psychiatric injury.
Brief description of psychiatric injury assessed:
I certify that I have conducted a subsequent examination today in relation to the same psychiatric injury (which has not arisen as a consequence of, or secondary to, a physical injury) and I am unable to determine the degree of impairment. However, I am satisfied that the degree of impairment resulting from this psychiatric injury will satisfy the threshold level once the injury has stabilised.
SIGNED: DATED:
Please note:
This certificate must be provided by a medical practitioner who is an approved medical practitioner within the meaning of section 28LB of the Wrongs Act 1958.
This certificate must not state the specific degree of impairment.
Impairment is defined in section 28LB of the Wrongs Act 1958 to mean permanent impairment.
Threshold level is defined in section 28LB of the Wrongs Act 1958 to mean—
(a) in the case of injury (other than psychiatric injury or spinal injury), impairment of more than 5 per cent;
(b) in the case of psychiatric injury, impairment of 10 per cent or more;
(c) in the case of spinal injury, impairment of 5 per cent or more.
The date of the first examination of the person seeking an assessment must be at least 6 months before the date of this assessment.
The degree of psychiatric impairment must not have regard to any psychiatric or psychological injury, impairment or symptoms which has arisen as a consequence of, or secondary to, a physical injury—see section 28LJ of the Wrongs Act 1958.
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 toPart 3if 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 toPart 4if 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. DETAILS OF RESPONDENT/S
For each party that the claimant considers is a proper respondent to the claim, provide the following information:
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 the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
Note: This Part of Form 3 may be expanded as necessary to allow the details of all proper respondents to the claim to be included in the Form.
5. DESCRIPTION OF THE INCIDENT
Date of incident:
Time of incident:
Location of incident:
Description of incident:
6. THE INJURY TO THE CLAIMANT
Set out all the injuries claimed to have been suffered by the claimant as a result of the incident:
Provide details of the non-economic loss suffered by the claimant as a result of the injury:
Note: Under section 28LB of theWrongs Act 1958*,* non-economic lossis defined to mean any one or more of the following—
(a) pain and suffering;
(b) loss of amenities of life;
(c) loss of enjoyment of life.
7. DOCUMENTATION OF THE INCIDENT AND INJURY
If the claimant intends to rely on a report of the incident to make the claim:
Date of report:
Name of person to whom the report was made:
8. DETAILS OF MEDICAL PRACTITIONER/S
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:
Note: If a claimant has been treated by more than one medical practitioner, this Part of Form 3 may be expanded to include the details of any additional medical practitioners.
9. CERTIFICATION BY CLAIMANT (or claimant's legal representative)
Signature of claimant:
Date:
OR:
Signature of claimant's legal representative:
Date:
Note: Respondent must respond in writing to the claimant within 60 days.
Under section 28LO(2) of theWrongs Act 1958*, a respondent who has received this Form must respond in writing to the request within 60 days of receiving it.*
Form 4
Regulation 8
CLAIMANT PRESCRIBED INFORMATION FORM
Wrongs Act 1958
Section 28LT(2)
1. CLAIMANT'S NAME
Claimant's full name:
2. CLAIMANT'S DETAILS
Go toPart 3if 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 toPart 4if 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. DETAILS OF RESPONDENT/S
For each party that the claimant considers is a proper respondent to the claim, provide the following information:
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 the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
Name:
Address:
Telephone number: [leave blank if not known]
Reason why claimant asserts this party is the proper respondent to the claim:
Note: This Part of Form 4 may be expanded as necessary to allow the details of all proper respondents to the claim to be included in the Form.
5. DESCRIPTION OF THE INCIDENT
Date of incident:
Time of incident:
Location of incident:
Description of incident:
6. THE INJURY TO THE CLAIMANT
Set out all the injuries claimed to have been suffered by the claimant as a result of the incident:
Provide details of the non-economic loss suffered by the claimant as a result of the injury:
Note: Under section 28LB of theWrongs Act 1958*,* non-economic lossis defined to mean any one or more of the following—
(a) pain and suffering;
(b) loss of amenities of life;
(c) loss of enjoyment of life.
7. DOCUMENTATION OF THE INCIDENT AND INJURY
If the claimant intends to rely on a report of the incident to make the claim:
Date of report:
Name of person to whom the report was made:
8. DETAILS OF MEDICAL PRACTITIONER/S
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:
Note: If a claimant has been treated by more than one medical practitioner, this Part of Form 4 may be expanded to include the details of any additional medical practitioners.
9. CERTIFICATION BY CLAIMANT (or claimant's legal representative)
Signature of claimant:
Date:
OR:
Signature of claimant's legal representative:
Date:
Note:Respondent must respond in writing to the claimant within 60 days.
Under section 28LW(1) of theWrongs Act 1958*, a respondent on whom a copy of a certificate of assessment is served must respond in writing to the claimant within 60 days after receiving the certificate and the required information under section 28LT.*
If the respondent fails to respond in writing within the 60 days, the respondent is deemed to have accepted the assessment (section 28LW(4)).
Form 5
Regulation 9
NOTICE OF REFERRAL OF MEDICAL QUESTION TO MEDICAL PANELS
*🞏 Does the degree of impairment resulting from the psychiatric or psychological injury to the claimant alleged in the claim satisfy the threshold level?
Date on which the respondent received the certificate of assessment:
Date on which the respondent received Form 4 from the claimant:
5. ATTACHED DOCUMENTS
The following documents must be included as attachments to this Form:
🞏 Certificate of assessment received from the claimant
🞏 A copy of Form 4 received from the claimant
🞏 Statement of claim (if received from the claimant)
6. CERTIFICATION BY RESPONDENT (or respondent's legal representative)
🞏 I have advised the claimant that I have referred a medical question in relation to the assessment to a Medical Panel for determination.
Signature of respondent: Date:
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Endnotes
1 General information
See www.legislation.vic.gov.au for Victorian Bills, Acts and current Versions of legislation and up-to-date legislative information.
The Wrongs (Part VBA Claims) Regulations 2025, S.R. No. 18/2025 were made on 15 April 2025 by the Governor in Council under section 28LZP of the Wrongs Act 1958, No. 6420/1958 and came into operation on 4 May 2025: regulation 3.
The Wrongs (Part VBA Claims) Regulations 2025 will sunset 10 years after the day of making on 15 April 2035 (see section 5 of the Subordinate Legislation Act 1994).
INTERPRETATION OF LEGISLATION ACT 1984 (ILA)
Style changes
Section 54A of the ILA authorises the making of the style changes set out in Schedule 1 to that Act.
References to ILA s. 39B
Sidenotes which cite ILA s. 39B refer to section 39B of the ILA which provides that where an undivided regulation, rule or clause of a Schedule is amended by the insertion of one or more subregulations, subrules or subclauses the original regulation, rule or clause becomes subregulation, subrule or subclause (1) and is amended by the insertion of the expression "(1)" at the beginning of the original regulation, rule or clause.
Interpretation
As from 1 January 2001, amendments to section 36 of the ILA have the following effects:
• Headings
All headings included in a Statutory Rule which is made on or after
1 January 2001 form part of that Statutory Rule. Any heading inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.
This includes headings to Parts, Divisions or Subdivisions in a Schedule; Orders; Parts into which an Order is divided; clauses; regulations; rules; items; tables; columns; examples; diagrams; notes or forms.
See section 36(1A)(2A)(2B).
• Examples, diagrams or notes
All examples, diagrams or notes included in a Statutory Rule which is made on or after 1 January 2001 form part of that Statutory Rule. Any examples, diagrams or notes inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, form part of that Statutory Rule. See section 36(3A).
• Punctuation
All punctuation included in a Statutory Rule which is made on or after
1 January 2001 forms part of that Statutory Rule. Any punctuation inserted in a Statutory Rule which was made before 1 January 2001, by a Statutory Rule made on or after 1 January 2001, forms part of that Statutory Rule.
See section 36(3B).
• Provision numbers
All provision numbers included in a Statutory Rule form part of that Statutory Rule, whether inserted in the Statutory Rule before, on or after
1 January 2001. Provision numbers include regulation numbers, rule numbers, subregulation numbers, subrule numbers, paragraphs and subparagraphs. See section 36(3C).
• Location of "legislative items"
A "legislative item" is a penalty, an example or a note. As from 13 October 2004, a legislative item relating to a provision of a Statutory Rule is taken to be at the foot of that provision even if it is preceded or followed by another legislative item that relates to that provision. For example, if a penalty at the foot of a provision is followed by a note, both of these legislative items will be regarded as being at the foot of that provision. See section 36B.
• Other material
Any explanatory memorandum, table of provisions, endnotes, index and other material printed after the Endnotes does not form part of a Statutory Rule. See section 36(3)(3D)(3E).
2 Table of Amendments
There are no amendments made to the Wrongs (Part VBA Claims) Regulations 2025 by statutory rules, subordinate instruments and Acts.
3 Explanatory details
Reg. 4: S.R. No. 31/2015 as amended by S.R. No. 1/2016. ↑