access application
Government Information (Public Access) Act 2009
Please complete this form to apply for formal access to government information under the
Government Information (Public Access)
Act 2009 (GIPA Act). If you need thelp in filling out this form, please contact the Right to Information Officer on 02 9216 3500 or
xxxx@xxxxx.xxx.xxx.xx
Which of icare’s agencies are you applying to for information: (Please mark one box only)
icare NSW
Workers Insurance
Self Insurance
Dust Diseases Care
Lifetime Care
Sporting Injuries Insurance
hbcf
01. your details
Surname
Title
Other names
Postal address
Poscode
Day-time phone
Facsimile
Email
1.1 The questions below are optional and the information will only be used for the purposes of providing better service.
Main language spoken
Aboriginal or Torres Strait Islander
Yes
No
Do you have special needs for assistance with this application?
I agree to receive correspondence at the above email address.
02. proof of identity
When seeking access to personal information (including your own), an applicant must provide proof of identity in
the form of a
certified copy of any one of the following documents:
Australian driver’s licence
Current Australian passport
Other proof of signature and
with photograph, signature & current address
current address details
03. government information
Please describe the information you would like to access in enough detail to allow us to identify it.
Note: If you do not give enough details about the information, the agency may refuse to process your application.
It would assist if you could provide, claim number/ participant number/ date of injury/ employers name/ claim
manager eg: EML, Allianz etc (if you are aware):
Are you seeking personal information?
Yes
No
04. form of access
How do you wish to access the information?
Inspect the document(s)
A copy of the document(s)
Access in another way (please specify)
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icare | GIPA Access Application Form - 2017
access application
Government Information (Public Access) Act 2009
05. application fee
I attach payment of the
$30 application fee by
cheque
money order
(please DO NOT send cash)
06. consultation
The Agency may be required to consult with third parties before deciding your application. If the information you
are seeking contains information about another person, business or government agency, we are required by law to
ask whether they have an objection to the disclosure of their information. For the purposes of such consultation,
please indicate in the boxes below whether you consent to the release of the following information to any third
parties.
Do you object to this?
Yes
No
07. disclosure log
If the information sought is released to you and would be of interest to other members of the public, details about
your application may be recorded in the agency’s ‘disclosure log’. This is published on the agency’s website.
Do you object to this?
Yes
No
08. discount in processing charges
You may be asked to pay a charge for processing the application ($30 / hour). Some applicants may be entitled to
a 50% reduction in their processing charges. If you wish to apply for a discount, please indicate the reason:
Financial hardship - please attach supporting documentation (eg a person or Centrelink card).
AND / OR
Special benefit to the public - please specify why below:
Applicant’s signature
Date
Please include your application fee of
$30 when you post this form to:
Government Information (Public Access) Officer, icare, GPO Box 4052, Sydney NSW 2001
Note: if you email your application processing will not commence until icare receives
a money order or cheque for the application fee.
General information about GIPA Act is available by calling the Information and Privacy Commission on
1800 472 679 or visit the IPC’s website: www.ipc.nsw.gov.au
office use only
Date application received: ____________________________
File reference: ______________________________________
Date of decision: ____________________________________
GIPA Access Application Form - 2017 |
icare 2
