Compensation and damages

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1 tes for Compensation and damages Purpose of this form Definition of a partner What you must tell us Are you receiving or about to receive compensation? This form is part of your claim for payment and is used to calculate your rate of payment or to review your entitlement under the Social Security Act 1991 or Student and Youth Assistance Act For the Australian Government Department of Human Services purposes a person is considered to be your partner if you and the person are living together, or usually live together, and are: married, or in a registered relationship (opposite-sex or same-sex), or in a de facto relationship (opposite-sex or same-sex). We consider a person to be in a de facto relationship from the time they commence living with another person as a member of a couple. We recognise all couples, opposite-sex and same-sex. If you receive a Centrelink payment or apply for one in the future, you must tell us about any compensation payment you or your partner receive or have applied for. You must also tell us if you or your partner are entitled to receive compensation but have not applied for it yet. If you already receive a Centrelink payment, you must tell us within 7 days of you or your partner receiving a compensation payment. You must also tell us within 14 days of any change to the rate of regular compensation payments you or your partner receive. There are penalties for not doing this. What you need to know before you settle your compensation claim If you are about to receive regular compensation payments or a lump sum for personal injury then you should be aware of how this will affect your Centrelink payments. Personal injury compensation can be paid for a work related illness, injuries from a car accident, or for any other reason due to the negligence or fault of another person. Payments under a sickness or accident policy where the payment is reduced (offset) because the claimant has received payments from us also count as How may I be affected? If you have an accident, for which you may be able to get compensation, and you apply for Centrelink payments, we can ask you to claim You may not get Centrelink payments until you do. Regular compensation payments If you get regular weekly, monthly or fortnightly payments of compensation (e.g. workers compensation) and you apply for Centrelink payments, the payments that you get through us can be reduced by a dollar for every dollar of What if I have to wait for my compensation payments to begin and need to claim Centrelink payments while I wait? If you receive Centrelink payments while you are waiting for your compensation payments to start, you will have to repay some or all of the payments you received from us, when you receive your Example: If you receive $1,250 in Centrelink payments then later receive a back payment of $2,000 in compensation monies for the same period, you will have to pay us back $1,250 from your Please keep these tes (pages 1 to 4) for your information. tes 1 of 4

2 What if I receive a lump sum compensation payment? We work out the period of time your payment covers this period of time is called the preclusion period. During the preclusion period you cannot be paid most Centrelink payments. The preclusion period generally starts from the time that any regular compensation ceases. If you had no earlier compensation, it will start from when your loss of earnings began. Preclusion periods can start in the past and run into the future. If you received Centrelink payments during the preclusion period you will have to pay back all the Centrelink payments you received during that period. You may still be able to get a Health Care Card, Commonwealth Seniors Card, Carer Allowance or Mobility Allowance during the preclusion period if you apply and are eligible. Family payments are not usually affected by How do I repay money? We will normally arrange any repayment with your insurance company or compensation provider. The Centrelink payments paid to you while you waited for your compensation to be paid will be deducted from any back payment of regular compensation or from the lump sum. You will then be paid the balance of the It is very important that you take into account the repayment of Centrelink payments and any future preclusion period when you are taking action to invest or spend your compensation payment. Before you start to spend your compensation payment you should find out if you have to repay any Centrelink payments and when you can start to get Centrelink payments. It is in your best interest to do this before you make any decisions about your future. How does a compensation payment affect couples? What to do before you agree to accept a compensation payment If your partner also receives income support, their payments may be affected by your regular compensation payments and any other income you or your partner may receive. If your Centrelink payments have been reduced to nil and there is still an amount of compensation left over, the amount left over is then treated as ordinary income for your partner. If you receive a lump sum compensation payment, your partner will not be affected by the preclusion period and they can still be paid Centrelink payments provided they are otherwise eligible. When a settlement is pending you, or your solicitor on your behalf, can take advantage of the compensation online estimate service. To access the estimator, go to our website The compensation online estimator will advise you: how a proposed lump sum compensation payment may affect Centrelink payments, if you will need to repay any Centrelink payments from your compensation payment, and whether your compensation payment(s) will stop you from receiving a payment in the future, and if it does, when the period starts and finishes. What you should tell your solicitor You should tell your solicitor about any payment(s) you have received from us since your accident/injury, or that you may apply for in the future. You should also ask your solicitor for a Compensation Estimate of Centrelink Charge/Preclusion. To access the compensation online estimator, go to our websitewww.humanservices.gov.au/centrelinkcompensationrecovery It is important that you get this information before you agree to accept the compensation payment(s) and before you make any decisions about spending or investing the tes 2 of 4

3 Other help For more information If you have a hearing or speech impairment Interpreters and translations What else you will need to provide Returning your form(s) We have Financial Information Service Officers who can help current and future customers make informed decisions about their investment and financial issues. This service is free, independent and confidential. You can make an appointment to talk to a Financial Information Service Officer by calling Go to our websitewww.humanservices.gov.au/business or call us on or visit one of our Service Centres for general information including compensation, or the Department of Social Services websitewww.dss.gov.au for access to social security law and policy. To speak to us in languages other than English, call te: Call charges apply calls from mobile phones may be charged at a higher rate. TTY service Freecall A TTY phone is required to use this service. If you need an interpreter or translation of any documents for our business, we can arrange this for you free of charge. This form tells you which other documents you need to provide. Check that you have answered all the questions you need to answer and that you have signed and dated this form. If you return required documents (and your form): online you can submit your documents online if you are registered for Online Services. by post we will sight and record your documents, which may include copying, and return the originals to you by registered post. in person we will sight and record your documents, which may include copying, and return the originals to you. Return this form, all additional documents and any other forms you are required to complete to one of our Service Centres or online within 14 days to make sure you are paid from the earliest date possible. If you cannot return all the forms or documents within 14 days, contact us for extra time. For more information on how to access Online Services or how to lodge documents online, go to tes 3 of 4

4 Information in other languages tes 4 of 4

5 Compensation and damages MOD C Customer name Date of birth Return this form online or to one of our Service Centres by Your Centrelink Reference Number Contact phone number This form is part of your claim for payment and is used to calculate your rate of payment or to review your entitlement under the Social Security Act 1991 or Student and Youth Assistance Act Please answer all the questions. If you do not answer all the questions on this form, assessment of your Centrelink entitlement may be delayed. Please complete a separate Compensation and damages form (Mod C) for you (or your partner) for each compensation injury or claim. Under section 1166 of the Social Security Act 1991, if we believe you have an entitlement to compensation we can require you to take reasonable action to obtain that Filling in this form - Please use black or blue pen. - Print in BLOCK LETTERS. - Mark boxes like this with a or. - Where you see a box like this Go to 5 skip to the question number shown. You do not need to answer the questions in between. Who needs to complete this form? Only the person who has claimed, or will be claiming, a compensation payment must complete and sign this form. If you need additional documents listed in this form go to our website or contact us. 2 3 The following questions must be completed by the person claiming compensation or their authorised representative. In whose name was this compensation claim made, or will be made? Mr Mrs Family name First given name Second given name Miss Ms Other Have you ever used or been known by any other name (e.g. name at birth, maiden name, previous married name, Aboriginal or tribal name, alias, adoptive name, foster name)? Give details below 1 Other name Type of name (e.g. name at birth) 1 Who has claimed, is claiming, or is eligible to claim the compensation payment? 2 Other name You Your partner Other Your partner needs to complete and sign the remaining questions about the claim for The following questions are to be completed about the person claiming This person or their authorised representative (e.g. Centrelink nominee, Power of Attorney) must sign this form. Type of name (e.g. maiden name) If you have more than 2 other names, attach a separate sheet with details. CLK0Mod(C) of 3

6 4 Compensation payer s details Name Address Phone number Compensation payer s claim number Postcode 9 What type of compensation has been or will be claimed? Worker s compensation Motor Vehicle Criminal Injuries/ Victim s compensation Sporting injury Public Liability Medical Negligence Personal Accident and Sickness Insurance or Income Replacement Insurance Other Give details below 5 What is the date of the injury or illness? Attach a copy of supporting documentation. 6 What is the start date of the loss of earnings because of injury or illness? 10 Have regular compensation payments ever been paid? Go to 12 7 Where did the injury or illness occur? At work Travelling to or from work Other Give details below 11 Have the payments stopped? When did these payments stop? 8 In what state or territory did the injury or illness occur? 12 Are regular compensation payments being pursued? 13 Has a lump sum compensation payment been paid? What was the amount of the lump sum? $ When was the lump sum paid? Go to Is a lump sum compensation payment being pursued? te: A separate Compensation and damages form (Mod C) will have to be completed for each compensation injury or claim. 2 of 3 15 Have you made or intend to claim any other compensation claims? te: A separate Compensation and damages form (Mod C) will have to be completed for each compensation injury or claim.

7 16 Do you, or did you have, a solicitor acting for you in this claim for compensation? Give details below Name of solicitor Name of solicitor s firm 18 IMPORTANT INFORMATION Privacy and your personal information Your personal information is protected by law, including the Privacy Act 1988, and is collected by the Australian Government Department of Human Services for the assessment and administration of payments and services. This information is required to process your application or claim. Address Your information may be used by the department or given to other parties for the purposes of research, investigation or where you have agreed or it is required or authorised by law. Postcode You can get more information about the way in which the Department of Human Services will manage your personal information, including our privacy policy at www. humanservices.gov.au/privacy or by requesting a copy from the department. Phone number 19 Statement 17 Have you claimed or are you claiming compensation from an employer? te: Under Section 1166 of the Social Security Act 1991, if we believe you have an entitlement to compensation we can require you to take reasonable action to obtain that I declare that: the information provided in this form is complete and correct. I understand that: giving false or misleading information is a serious offence. the Australian Government Department of Human Services can make relevant enquiries to make sure I receive the correct entitlement and/or I am eligible for a concession card. Give details below Your signature Employer s business name Address Date Postcode Phone number Office Use Only Service Centre scan any additional documents relating to the compensation claim. For personal sickness and accident claims scan a copy of the Insurance Policy. 3 of 3

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