Instructions
Compensation Advice of
Lump Sum Payments
1
Claimant's compensation details
Title
Mr
Mrs
Miss
Ms
Other
Name of claimant
Previous names(s) (e.g. name
at birth, maiden name)
Date of birth
Sex
Male
Female
Address of claimant
Postcode
(
Contact phone number
)
Mobile phone number
Centrelink Reference Number
(if known)
Compensation ID
2
Compensation claim details
Date of injury/illness
Date last worked
Type of claim
Workers' compensation
Type of Lump Sum
Compensation Payment
Consent agreement or settlement
Workers'
Employer's name
compensation
claim only
Employer's phone number
Insurer's/Compensation Payer's
details
Other
Give details
below
verdict/tribunal/court judgement
You will need to attach a copy of
the settlement documentation.
Date settlement signed
3
Motor vehicle
(
)
Name
Reference Number
Postal address
Postcode
Office claim is held
Claim officer's name
4
Are there any OTHER INSURERS/
COMPENSATION PAYERS involved in
the compensation settlement?
Contact phone number
(
)
Fax number
(
)
No
Yes
Give details Name
1.
Reference Number
2.
CLK0SS446 1312
SS446.1312
1 of 2
5
Is there more than one
No
compensation claim being settled?
Date of injury
Yes
Give details below
Insurer Reference Number
Section of Act Gross amount of payment
$
$
You will need to attach a copy of the settlement documentation for each compensation claim being settled.
6
If you need more space, attach a separate sheet with details.
Has the claimant received any other No
Yes
Give details below
lump sum compensation payments
for these claims?
Date of injury
Insurer Reference Number
Date of settlement
Section of Act Gross amount of payment
$
$
7
8
If you need more space, attach a separate sheet with details.
Did the current settlement contain No
Yes
a component for economic loss?
Has the claimant received periodic
compensation in respect of this
claim?
No
When did the loss of earnings commence?
Yes
What is the date to which
periodic payments of
compensation ceased
i.e. by insurer or employer
or by reimbursement?
9
What is the total gross lump sum
$
settlement amount?
Includes costs, medical costs, Medicare,
periodics and rehabilitation costs.
10 Will there be a payback of periodic No
compensation payments required
to be made from the gross lump
sum amount?
11 Is this a lump sum of periodics for a
fixed period (e.g. redemption)?
No
for date of injury
for date of injury
for date of injury
You will need to attach a copy of the settlement documentation.
Yes
Tick ONE only This is: inclusive
exclusive
of the gross lump sum amount.
Who will these be paid to:
What is the amount of
periodics to be repaid: $
Insurer's/Compensation
Payer's reference no.
Yes
Gross amount $
Period
12 Were other components paid with
this lump sum (e.g. pain and
suffering, medical costs, interest)?
No
13 Is the claimant pursuing or
entitled to pursue any FURTHER
compensation payments from
this claim?
No
Yes – periodic payments
Yes – lump sum
Yes
You will need to attach a copy of
the payment schedule.
to
Gross amount $
You will need to attach a copy of
the settlement documentation.
14 What date will the money be
released to the claimant or their
legal representative?
15 IMPORTANT INFORMATION — Privacy and 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.
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.
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 humanservices.gov.au/privacy or by requesting a copy from the department.
www.
16 Insurer's/Compensation payer's signature
Signature
Printed
name
Date
SS446.1312
2 of 2
On completion of this form,
please print and sign by hand.
Print
Clear