Compensation and damages
|
|
- Meredith Park
- 8 years ago
- Views:
Transcription
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
MOD. Business details. Purpose of this form. Definition of a partner. For more information. If you have a hearing or speech impairment
Business details MOD F Return this form online or to one of our Service Centres by Your Centrelink Reference Number Purpose of this form Definition of a partner For more information If you have a hearing
More informationCompensation kit. What you need to know. humanservices.gov.au
Compensation kit What you need to know humanservices.gov.au 2 Compensation kit Contents What you need to know...4 Compensation and social security law: an overview...5 What is compensation?...5 What Centrelink
More informationNotes for Child Care Benefit for registered care
tes for Child Care Benefit for registered care Purpose of these notes For more information These notes provide information for people using registered child care who want to claim Child Care Benefit. With
More informationMOD. Real estate details. When to use this form. Definition of a partner. For more information. If you have a hearing or speech impairment
Real estate details MOD R Return this form online or to one of our Service Centres by Your Centrelink Reference Number When to use this form Definition of a partner For more information If you have a hearing
More informationApplication to copy or transfer from one Medicare card to another
Application to copy or transfer from one Medicare card to another When to use this form Use this form if you need to do any of the following 4 actions: Transfer to a new Medicare card When a person transfers
More informationClaim for Compensation for a Work-related death
SRC 184 (March 2014) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act)
More informationClaim for Approved Child Care payments
Claim for Approved Child Care payments an annual lump sum payment for the 2014 2015 financial year Online Services When to use this form When to Claim Filling in this form Use our online services You do
More informationClaim for an annual lump sum payment of Family Tax Benefit
Claim for an annual lump sum payment of Family Tax Benefit A payment to help families with the cost of raising children for the 2014 2015 financial year Online Services When to use this form When to Claim
More informationRequest for Jobs, Education and Training Child Care fee assistance
Request for Jobs, Education and Training Child Care fee assistance When to use this form Filling in this form Use this form to apply for Jobs, Education and Training (JET) Child Care fee assistance. You
More informationRelationship Details outside Australia
Relationship Details outside Australia Your Centrelink Reference Number Return this form to the Department of Human Services International Services by How do we assess your relationship? If you cannot
More informationCompensation and its effect on social security. What is not treated as compensation?
factsheet Compensation and its effect on social security I This factsheet explains how receiving compensation may prevent you from receiving a social security payment, or you may have your payment reduced.
More informationHealth Care Card. Claim for a. When to use this form. Online Services. Filling in this form. Returning your form. For more information.
Claim for a Health Care Card When to use this form Online Services Filling in this form Returning your form For more information Use this form to claim one of the following: A Low Income Health Care Card
More informationClaim for Compensation for a Work-related death
SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the
More informationDisaster Recovery Allowance Tropical Cyclone Marcia (Qld) February 2015
Disaster Recovery Allowance Tropical Cyclone Marcia (Qld) February 2015 1 Do you need an interpreter when dealing with us? 7 Do any of the following apply to you? This includes an interpreter for people
More informationClaim for Special Child Care Benefit and/or increased weekly limit of hours
Claim for Special Child Care Benefit and/or increased weekly limit of hours When to use this form Special Child Care Benefit (rate) for hardship, and/or Increased weekly limit of hours due to exceptional
More informationCompensation and its effect on Social Security
Compensation and its effect on Social Security This Factsheet explains how receiving compensation may prevent you from receiving a Social Security payment, or you may have your payment reduced. However
More informationDisaster Recovery Allowance NSW East Coast Storms and Flooding April 2015
Disaster Recovery Allowance NSW East Coast Storms and Flooding April 205 Do you need an interpreter when dealing with us? 7 Do any of the following apply to you? This includes an interpreter for people
More informationDisaster Recovery Allowance South Australia Pinery Bushfire November 2015
Disaster Recovery Allowance South Australia Pinery Bushfire vember 2015 1 Please read this before answering the following questions. The Disaster Recovery Allowance is for people who can demonstrate they
More informationCLAIM FOR WORKERS COMPENSATION
CLAIM FOR WORKERS COMPENSATION Seafarers Rehabilitation and Compensation Act 1992 Information about claiming workers compensation In this document, all references to the employer mean the employer against
More informationNotes Booklet for Claim for Dad and Partner Pay
tes Booklet for Claim for Dad and Partner Pay Online Services When to use this form When to claim For more information Use our online services You do not need to complete this form if you use our online
More informationContributions splitting
Instructions for and subject form for super fund members Contributions splitting How to complete your Superannuation contributions splitting application. BEFORE COMPLETING THIS APPLICATION Contact your
More informationCLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH
CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH Seafarers Rehabilitation and Compensation Act 1992 Information about claiming compensation In this document, all references to the employer mean the employer
More informationNotes for claiming Australian pension
tes for claiming Australian pension Social Security Agreement between Australia and the USA When to use this form For more information Use this form to claim an Australian pension. te: The date from which
More informationTax file number declaration
instructions and form for taxpayers Individuals Tax file number declaration The information you provide in this declaration will enable your payer to work out how much tax to withhold from payments made
More informationABSTUDY Remote Areas
Information you need to know about your claim for ABSTUDY Remote Areas Purpose of this form For more information If you have a hearing or speech impairment Interpreters and translations ABSTUDY is for
More informationPayment of unclaimed superannuation money
Instructions and form for super fund members Payment of unclaimed superannuation money How to complete your Application for payment of unclaimed superannuation money individual. For information about unclaimed
More informationDefence Bank Pension Pension Tax File Number Declaration
Defence Bank Pension Pension Tax File Number Declaration < Instructions This declaration is NOT an application for a tax file number. Please print neatly in BLOCK LETTERS and use a BLACK pen. Print X in
More informationAPPLICATION FORM - PERSONAL INJURY (Do not use for fatal injuries)
The Compensation Agency Royston House 34 Upper Queen Street Belfast BT1 6FD www.compensationni.gov.uk THE COMPENSATION Agency Reference number For official use only T1 Criminal Injuries Compensation Scheme
More informationMedicare enrolment application
Medicare enrolment application When to use this form Use this form if you are: a migrant living in Australia applying for permanent residency and living in Australia a visitor to Australia an Australian
More informationYour Centrelink Reference Number
Income and Assets MOD ia Return this form online or to one of our Service Centres by r Centrelink Reference Number Purpose of this form Filling in this form Returning your form(s) For more information
More informationCan the TAC help you?
Can the TAC help you? The Transport Accident Commission (TAC) pays for the reasonable cost of treatment and support services for people injured in transport accidents. You may be eligible to have medical
More informationIncome and Assets. Purpose of this form. If you have a partner. Online Services. Filling in this form. Returning your form. For more information
Income and Assets Purpose of this form If you have a partner Online Services Filling in this form Returning your form For more information This form asks you to provide information about your income and
More informationFact Sheet > Super SA > Triple S > Your Questions Answered MAKING AN INCOME PROTECTION CLAIM
Fact Sheet > Super SA > Triple S > Your Questions Answered MAKING AN INCOME PROTECTION CLAIM > 1 IN THIS FACT SHEET > What is Income Protection (IP)? > Circumstances under which IP will not be paid > Step
More informationApplication for assistance
Application for assistance Your personal details Title Mr Mrs Ms Miss Other u Give details Family name First name Middle names Do you use or have you used other names? (eg maiden name or previous married
More informationTax return for individuals 2015 1 July 2014 to 30 June 2015
Use Individual tax return instructions 2015 to fill in this tax return n Print clearly using a black pen only n Use BLOCK LETTERS and print one character in each box S M I T H S T Individual information
More informationNotes for Private Trust
tes for Private Trust Purpose of this form When to complete this form Definition of a partner For more information If you have a hearing or speech impairment Interpreters and translations The information
More informationTax file number application or enquiry for an individual
Tax file number application or enquiry for an individual ABOUT TAX FILE NUMBERS The tax file number (TFN) is a unique number issued by the Tax Office to individuals and organisations to help the Tax Office
More informationYouth Allowance or ABSTUDY
Youth Allowance or ABSTUDY Unreasonable to live at home Statement by Independent Third Party Return this form to one of our Service Centres by at the following address Name of young person claiming Unreasonable
More informationHome Ownership Expression of Interest
OFFICE USE ONLY Lead no: Home Ownership Expression of Interest Complete this form if you wish to register your interest in an Indigenous Business Australia (IBA) housing loan. Once completed, submit the
More informationTax file number declaration
Instructions and form for taxpayers Individuals Tax file number declaration Information you provide in this declaration will allow your payer to work out how much tax to withhold from payments made to
More informationApplication for a departing Australia superannuation payment
Instructions and form for temporary residents Application for a departing Australia superannuation payment How to complete your Application for a departing Australia superannuation (super) payment. WHO
More informationApplication for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application
Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application Losing a family member in a motor vehicle accident is a traumatic and difficult experience. The Motor Accidents
More informationMotor Accident Personal Injury Claim Form
Motor Accident Personal Injury Claim Form HAVE YOU BEEN INJURED IN A MOTOR VEHICLE ACCIDENT? If you have been injured in a motor vehicle accident in New South Wales, you may be able to access benefits
More informationSuperannuation lump sum pre-payment statement
Instructions and form for Super providers and members Superannuation lump sum pre-payment statement WHO SHOULD COMPLETE THIS STATEMENT? You should complete this statement if you: n are a super fund, approved
More informationHow to complete the PAYG payment summary individual non business
Instructions for PAYG withholding payers How to complete the PAYG payment summary individual non business Instructions to help you complete PAYG payment summary individual non business (NAT 0046) WHEN
More informationPublic Sector Injury Benefit Scheme 2015
Public Sector Injury Benefit Scheme 2015 PSPA Ref: Application for Injury Benefit Important: Please complete this form in CAPITAL LETTERS and in BLACK INK Section A To be completed by the Employing Authority
More informationCessation of employment
SR1 04/12 Cessation of employment Benefit application form Before you start Before you complete this benefit application form, please read the CSS Product Disclosure Statement. This form and the Explanatory
More informationForm 275 Notice of claim for damages
Department of Justice and Attorney-General Workers Compensation Regulator Form 275 Notice of claim for damages Version 3 Workers Compensation and Rehabilitation Act 2003 Section 275 This is an approved
More informationInstructions and form for individuals living outside Australia. Tax file number application or enquiry for individuals living outside Australia
Instructions and form for individuals living outside Australia Tax file number application or enquiry for individuals living outside Australia NAT 2628 04.2014 INTRODUCTION YOUR TAX FILE NUMBER (TFN) AND
More informationInformation Booklet about your claim for Family Assistance making an annual lump sum claim for payment
Information Booklet about your claim for Family Assistance making an annual lump sum claim for payment Use our online services You can claim these payments online. Claiming online is faster. You can access
More informationApplication for release
Application for release Write clearly, using a black pen only. Place X in all relevant boxes. If there is not enough space to provide full details, write the additional information on a separate page.
More informationI ve been injured at work. What do I do? Information for workers
The Application for Compensation form is an approved form under the Workers Compensation and Rehabilitation Act 2003. The general information contained on this and the following two pages are not part
More informationRetirement Lump Sum application information (Issued under sections 27, 149, 150, 151 and 213 of the Veterans Support Act 2014)
Retirement Lump Sum application information (Issued under sections 27, 149, 150, 151 and 213 of the Act 2014) Please read before you complete this form This application form is for veterans reaching the
More informationCLAIMS HANDLING GUIDELINES. for CTP Insurers
CLAIMS HANDLING GUIDELINES for CTP Insurers Initially issued 2000 Reissued: 1 July 2004; 18 September 2006; 1 July 2008; 1 October 2008, 1 May 2014 INTRODUCTION The MAA Claims Handling Guidelines (the
More information1. Claimant Details. personal accident and sickness claim form
personal accident and sickness claim form Wesfarmers General Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461 Level 2, 99 Melbourne Street, South Brisbane, QLD 4101 or GPO Box 524 Brisbane,
More information1. Personal Statement
journey injury claim form WFI Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461, Freecall 1300 651 654 IMPORTANT INFORMATION - Read before completing this form. (The issuing of this form is
More informationNotes for claiming Australian pension
tes for claiming Australian pension Social Security Agreement between Australia and New Zealand When to use this form For more information Use this form to claim an Australian pension. te: The date from
More informationAPPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries)
The Compensation Agency Royston House 34 Upper Queen Street Belfast BT1 6FD www.compensationni.gov.uk THE COMPENSATION Agency Reference number For official use only T4 Criminal Injuries Compensation Scheme
More informationBlue Care Income Protection Claim Form
Blue Care Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields
More informationNeeding help after someone has died?
March 2012 Needing help after someone has died? humanservices.gov.au Help in other languages If you need an interpreter or documents translated for your business with us, we can arrange this for you free
More informationApplication for direct payment of government super contributions
Instructions and form for retirees and estate trustees Application for direct payment of government super contributions WHO COMPLETES THIS APPLICATION You should complete this application if you want to
More informationYour People, Protected. Sports group Personal Accident Claim Form
Your People, Protected Sports group Personal Accident Claim Form Sports group Personal Accident/Claim Form 2 Claim Form Dear Member, IMPORTANT INFORMATION, relevant to YOUR Claim, is contained on this
More informationAs an aged care worker, this incentive is for you to upgrade your qualifications and build your career in aged care.
Aged Care Education and Training Incentive Programme COMMENCEMENT PAYMENT This application form is to be completed by eligible aged care workers who have enrolled and commenced studies to enhance their
More informationWorkers Compensation claim form
Form Workers Compensation claim form STOP - this form is available to be filled in electronically on the NT WorkSafe web site www.worksafe.nt.gov.au. Fill the form in electronically then save a copy to
More informationEmployer Insurance Application
for Property Focused Employer Sponsored Super Before you sign this application form, the Trustee or your financial adviser is obliged to give you the Property Focused Super Product Disclosure Statement
More informationDeduction for personal super contributions
Instructions for super fund members Deduction for personal super contributions How to complete your Notice of intent to claim or vary a deduction for personal super contributions This form should only
More informationApplication for Compensation
Application for Compensation This Application for Compensation form for injured workers is an approved form under the Workers Compensation and Rehabilitation Act 2003 (the Act). The general information
More informationMotor Accident Notification Form (MANF)
Motor Accident tification Form (MANF) As prescribed under section 84(2)(a) of the Road Transport (Third-Party Insurance) Act 2008 For Compulsory Third-Party (CTP) Insurance Claims in the Australian Capital
More informationEarly release of super on compassionate grounds How to make a claim
Early release of super on compassionate grounds How to make a claim Please note if you have ceased work due to sickness or injury, call us on 13 11 84 before proceeding. Am I eligible to make a claim?
More informationAdvance Retirement Suite Super Early Release Financial Hardship Application
Advance Retirement Suite Super Early Release Financial Hardship Application Trustee: BT Funds Management Ltd (BTFM) ABN 63 002 916 458 AFSL 233724 GUIDE TO COMPLETING THIS FORM > > Use this form if you
More informationTasmanian Accumulation Scheme Death and Incapacity Cover
Death and Incapacity Cover Retirement Benefits Fund Tasmanian Accumulation Scheme Death and Incapacity Cover Information in this brochure is current as at 18 January 2012 Retirement Benefits Fund Tasmanian
More informationAPPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries)
Compensation Services 6th Floor Millennium House 17-25 Great Victoria Street Belfast BT2 7AQ Telephone: 0300 200 7887 Criminal Injuries Compensation Scheme (2009) Made under the Criminal Injuries Compensation
More informationFIRST HOME OWNER RATE OF DUTY INDIAN OCEAN TERRITORIES
FIRST HOME OWNER RATE OF DUTY INDIAN OCEAN TERRITORIES SECTIONS 141 146 OF THE DUTIES ACT 2008 (WA)(CI) & (CKI) APPLICATION FORM AND LODGMENT GUIDE A first home owner who is not eligible for the First
More informationFarm Household Allowance Farm Financial Assessment
Farm Household Allowance Farm Financial Assessment What is the Farm Financial Assessment? Online Services The Farm Financial Assessment is an assessment of your and your partner s financial situation and
More informationFORM 2 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Health Care Claims)
FORM 2 PERSONAL INJURIES PROCEEDINGS ACT 2002 NOTICE OF CLAIM (Health Care Claims) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ATTACHED AS THE LAST THREE PAGES OF THE FORM PLEASE READ INSTRUCTIONS CAREFULLY
More informationAs an aged care worker, this incentive is for you to upgrade your qualifications and build your career in aged care.
Aged Care Education and Training Incentive Programme COMPLETION PAYMENT This application form is to be completed by applicants who have completed studies and have already received a commencement payment
More informationMotor Accident Notification Form
Motor Accident tification Form This form is Approved Form AF2014-59, approved on 26 August 2014 by Karen Doran, delegate of the director-general, under section 276 of the Road Transport (Third- Party Insurance)
More informationWithdrawals. 1. Investor details
MLC Navigator Investment Plan MLC Navigator Retirement Plan MLC Navigator Access Investment MLC Navigator Access Super and Pension Withdrawals Please tick where appropriate: Account closure (Sections 1,
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More informationMesothelioma and other lung diseases
Mesothelioma and other lung diseases Application for a payment Fill in this form if you suffer from diffuse mesothelioma or another lung disease, or you were the partner of a sufferer who has died, or
More informationNT WORKERS COMPENSATION CLAIM FORM
Information for Workers Guidance to PART 1 of the Claim Form Notify your employer of your injury, verbally or in writing, as soon as practicable. Fully complete PART 1 (questions 1 to 8) of the following
More informationLife Events/Salary Increase cover
Fact sheet and form Life Events/Salary Increase cover What this fact sheet covers This fact sheet provides information about Life Events insurance cover and Salary Increase cover available through our
More informationFORM 1 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Non-Health Care Claims)
FORM 1 PERSONAL INJURIES PROCEEDINGS ACT 2002 NOTICE OF CLAIM (Non-Health Care Claims) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ATTACHED AS THE LAST THREE PAGES OF THE FORM PLEASE READ INSTRUCTIONS CAREFULLY
More informationPERSONAL INJURY CLAIM FORM
Office use only Policy Number: 0028332 Claim Number: s PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TENPIN BOWLING AUSTRALIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised
More informationSPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form
SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form Dear Member, Thank you for your Claim Form request. This letter contains important information relevant to your
More informationYour People, Protected. Personal Accident and Sickness Cover Claim Form
Your People, Protected Personal Accident and Sickness Cover Claim Form Personal Accident and Sickness Cover/Claim Form 2 Personal Accident and Sickness Cover Claim Form IMPORTANT INFORMATION We act upon
More informationRedundancy. Benefit application form. Before you start SRR1 01/14. What we need from you. What you can expect from us
SRR1 01/14 Redundancy Benefit application form Before you start Before you complete this benefit application form, please read the CSS Product Disclosure Statement. This form and the Explanatory notes
More informationRequest for VET FEE-HELP assistance
Before completing this form, you must read the VET FEE-HELP information booklet, available at www.studyassist.gov.au. You must: complete this form if you are requesting for all or part of your VET tuition
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More informationInformation you need to know about your claim for
Parenting Payment A payment for the principal carer of the child(ren). Information you need to know about your claim for Parenting Payment is a social security payment paid by the Australian Government
More informationNotice of intent. Fact sheet and form. What this fact sheet covers. Who is this fact sheet for? When should I complete a notice of intent?
Fact sheet and form Notice of intent A notice of intent to claim or vary a deduction for personal super contributions (notice of intent) allows you to claim a tax deduction for your personal contributions,
More informationINTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM
1 of 7 INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement The claimant is to complete all
More informationFlexible Lifetime Super
Issued ₁ July ₂₀₁₅ Flexible Lifetime Super Insurance fact sheet Registered trademark of AMP Life Limited ABN 84 079 300 379. This document is a fact sheet for the product disclosure statement (PDS) dated
More informationClaim for Workers Compensation
Claim for Workers Compensation This form is to be completed if you wish to claim workers compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act). Key features of the scheme are
More informationPersonal injury claims advice solicitors
Personal injury claims advice solicitors If you've suffered an accident or a personal injury that wasn't your fault, you could be entitled to make a compensation claim. Millbank solicitors personal injury
More informationQuestionnaire Cornwell-Type Claims
Sensitive: Personal once completed Questionnaire Cornwell-Type Claims Please complete all sections of this form and enter N/A in any section that is not applicable to indicate that the question has been
More informationIncome Protection Initial Claim Form
MLC Insurance Income Protection Initial Claim Form MLC Nominees Pty Limited ABN 93 002 814 959 AFSL 230702 RSE L0002998 The Universal Super Scheme ABN 44 928 361 101 R1056778 Superannuation Fund Number
More informationComplete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying super fund.
Benefit access Gesb Super and West State Super SUP E R ANNUATION Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying
More information(The issue of this form is not an admission of liability)
1 JOURNEY R CLAIM FORM M (The issue of this form is not an admission of liability) Trust Name: JLT (CAAW) Discretionary Trust ABN: 98 780 034 885 JLT Discretionary Trust and Excess of Loss Insurance This
More informationWeekly Compensation Scheme Two
Weekly Compensation Scheme Two Veteran s Personal Details 1 Veterans Affairs number (if known) 2 Title Rank Mr Mrs Ms Other 3 Last name 4 First name/s 5 Other name/s known as 6 Date of birth / / 7 Residential
More information