Notice of lump sum determination
return
Please refer to important information on the completion of this form are detailed on the next
page
Part A – Details of the claim
Tick relevant box
New return
Amended return
Worker’s surname:
Worker’s given
names:
Worker’s address:
Worker’s tel no:
Date of injury/death:
Date of birth:
Self-Insurer’s claim no:
Self-Insurer name:
Case manager name:
Case manager tel no:
RTWSA claim no:
Part B – Details of lump sum
s58 Non-Economic loss / s61 Death
Individual
Percentage of
amount/s
Detail the specific injury and body part affected
%
%
%
Total Whole Person Impairment %
Total s58/s61 Amount Paid
s56 Economic loss
LSU
$
Amount paid
Payment for Economic loss (s56)
RTWSA
Payment
Code
$
RTWSA
Payment
Code
LEL
Part C – Redemption s53 and s54
Total Amount
paid
Details of payment/s
s53 – Weekly Payments
s54 – Medical Services
Total Paid
$
$
$
RTWSA
Payment
Code
RDI
RDM
Part D – Deed of release s66 Liabilities discharged
Name of 3rd party wrongdoer and the whole amount of damages paid or
payable to worker by the wrongdoer
Wrongdoer (name)
Total Amount
paid
$
DOR
Part E– Supporting information
1.
RTWSA
Payment
Code
$
2.
Rate of weekly payment entitlement redeemed or liability discharged
(s49(2)/s49(3))
Date of determination, redemption agreement and/or deed of release
3.
Rate of NWE immediately prior to date of redemption or deed of release
$
4.
First date of incapacity (for purpose of section 47)
Notice of lump sum determination
5. return
Date of last weekly payment paid to worker prior to redemption
6.
Rate of worker’s entitlement to weekly payment as last determined
$
Notice of lump sum determination return Guidelines
Important information on the completion of the
Notice of Lump Sum Determination Return
Complete this return immediately following payment of a worker’s lump sum entitlement.
Part A:
1.
2.
Provide all details required of Part A. Identify whether the return is a new or amended return.
Assign the self-insured and ReturnToWorkSA claim numbers which the payment has been made
against.
Part B: In the case of a section 58 payment, detail the individual body parts assessed in the Whole Person
Assessment Report and the percentage of loss of function against each individual body part. Provide the
level of assessed WPI as a percentage and the amount paid. In the case of a section 56 payment, record
the amount paid.
Part C: Where applicable, record the amounts paid to the worker for the redemption of liabilities to pay
weekly payments and medical services.
Part D: Record the amount of damages retained by the worker and specified in the Deed of Release.
Part E:
1.
2.
3.
4.
5.
6.
Record the rate of weekly payments that the worker is taken to be receiving on redemption of that
liability for the purposes of section 49(2) and the rate of the weekly payment entitlement discharged
upon payment of the balance of the damages pursuant to a deed of release for the purpose of
section 49(3).
The date of the redemption agreement or deed of release.
The workers Notional Weekly Earning rate at the time of the redemption agreement or deed of
release.
The date of first incapacity, being the date on which the adjustment to the workers NWE under s47
would be required.
Record the date of the last weekly payment made to the worker prior to the redemption. Where no
weekly payments have been made record this field as NA.
Rate of the worker’s entitlement to weekly payment as last determined or determined by the tribunal
e.g. this may include a sealed order of the South Australian Employment Tribunal (SAET) reducing
the workers entitlement to weekly payments.
Other:
The following documents must be attached to this return where relevant:
1.
The section 58 lump sum determination letter identifying the lump sum payment and level of WPI
assessed. If a determination is made under section 56 of the Act, the determination which identifies
all factors specified by section 56(4) which demonstrate how the lump sum was calculated.
2.
The redemption agreement reflecting the lump sum amount(s) payable.
3.
The deed of release resulting from a third party common law action including the amount of
damages retained by the worker (which would otherwise have been payable to the
employer/compensating authority) and the rate of weekly payments the worker was receiving at the
time the deed of release was executed.
4.
Relevant sealed orders from the SAET.
5.
The determination (or sealed order of the SAET) which reduce the rate of a worker’s entitlement to
weekly payments relevant to:
a)
a deed of release – the rate of weekly payments the worker will be taken to be receiving under
section 49(3);
Notice of lump sum determination return Guidelines
6.
b) a redemption of liability to make weekly payments - the rate of weekly payments the worker will
be taken to be receiving under section 49(2).
Retain a copy of this return on the worker’s claim file.
7.
If additional rows are needed, expand the tables or print additional copies.
Send the completed return and relevant attachment(s) to lumpsumdata@rtwsa.com,
or post to Notice of Lump Sum Return, ReturnToWorkSA, GPO Box 2668, Adelaide SA 5001.