Attachment A
Telephone:
Claim Number: [Enter claim number]
[Enter addressee name]
[Enter address]
[Enter City/State/Postcode]
Dear [Enter addressee surname]
Safety, Rehabilitation and Compensation Act 1988
I am reviewing the information I have in relation to your compensation claim.
As a matter of good management practice and consistent with Commonwealth public sector legislation, standards and procedures, Comcare is obliged to review the information on claims on a regular basis.
Attached is a review form which requests information I need to ensure that our records are accurate and that you are receiving your correct entitlement.
Please note that in certain circumstances the information you provide may be given to any one of the parties listed on the front of the form.
I therefore request your assistance and cooperation. Please complete and sign the form in ink and return it to Comcare by [date 30 days from date of letter]. If you have any questions in relation to this form, please call [decision maker's name] on [decision maker's phone] or write to Comcare quoting the claim number stated above.
Yours sincerely
[Name]
for Comcare Australia
SL6/1 24 March 1998
|
l — Comcare is obliged by Commonwealth public sector legislation, standards and procedures as well as good management practice, to ensure that its information is accurate and up to date. In this way it can ensure that you are receiving your correct entitlement. l — Personal information is protected by the Privacy Act 1988 and so any information contained in this form is kept secure and will not be released to a third party without your consent, other than to those parties in the list below. In certain circumstances, information obtained during the course of a compensation claim or rehabilitation program may, according to their specific needs, be given to the following: Ø — Safety Rehabilitation & Compensation Commission Ø — An approved rehabilitation provider. Ø — Treating and/or other medical practitioners. Ø — Comcare's legal representatives. Ø — Courts, Tribunals and/or Commonwealth Agencies where there is an obligation under law to provide it. Ø — Comcare investigators. Ø — Your employer. Ø — Department of Veterans Affairs Ø — Law enforcement authorities. Ø — Relevant Ministers. Ø — Superannuation boards, and Ø — Centrelink |
PERSONAL DETAILS
Comcare Claim Number:-.................................
Title:........Given Name:.........................Surname: ..........................................
Former Name(s) used (if any.................................................................................
Sex:Female MaleDate of Birth: / /19
Residential Address;
Number/Street: ............................................................................................................
Suburb/Town.........................................................State:...............P/Code:..............
Telephone number: (H)(.....)..........................(W)(.....).........................
Postal Address (if different):
Postal Address:...........................................................................................................
Suburb/Town:...................................................... State:...............P/Code:..........
(When known, the above is to be completed by the Claims Manager)
Please answer all questions (in ink) with a written 'yes' or 'no' and further details provided where requested.
1.Is the above your current and permanent residential address?
........
If Yes, go to Q. 3
If No, go to Q.2
2.Please give details of your permanent residential address
Number/Street........................................................................
Suburb/Town:...........................................State:.........................P/Code:.....
3.Is the above your permanent telephone number?
........
If Yes, go to Q. 5
If No, go to Q.4
4.What is your permanent telephone number?
Telephone number: (H)(.....).........................(W)(.....)..............................
EMPLOYMENT DETAILS
Your entitlement to compensation may vary from time to time if you are working. Answering these details will allow Comcare to confirm the accuracy of your entitlement. If you are unsure about what constitutes employment or income please contact Comcare and check the details with us. Written advice can be provided or a meeting arranged to check your entitlements.
5.Are you currently working?
This question applies regardless of whether or not you receive income for that employment.
........
If Yes, go to Q. 6
If No, go to Q. 7
6.Please provide the following details.
Name of employer:...................................................................
Number/Street:........................................................................
Suburb/Town..............................State:.................P/Code:.........
Telephone Number: (....)....................................
Period of employment: ....../....../...... to ....../......./......
Number of hours worked per week: ........................./week
Gross weekly earnings (i.e. before any deductions) $........../week
7.Have you been employed at any time since you started receiving compensation?
This question applies regardless of whether or not you receive income for that employment.
........
If Yes, go to Q. 8
If No, go to Q.9
8.Please provide the following details:-
Employer Name:.....................................................................
Number/Street:........................................................................
Suburb/Town:..............................State:.................P/Code:.......
Telephone Number:(....)....................................
Period of employment: ....../....../...... to ....../......./......
Number of hours worked per week: ........................./week
Gross weekly earnings (ie before any deductions) $ ................/week
9.Are you self-employed in any capacity (e.g. business or partnership)?
This question applies regardless of whether or not you receive income from that self employment, business or partnership. I
........
If Yes, go to Q. 10
If No, go to Q. 11
10.Please provide the following details of the business or partnership.
Name of business or partnership:................................................
Number/Street:............................................. .....................
Suburb/Town:........................State:.................P/Code:..............
Telephone Number:(....)....................................
Period of employment/involvement: ....../....../...... to .../..../...
Number of hours worked per week: ................/week
Gross weekly earnings (i.e. before any deductions): $ ...............week
11.Have you been self-employed or involved in a business or partnership at any time since you started receiving compensation?(This question applies regardless of whether or not you receive income from that employment, business or partnership.)
........
If Yes, go to Q. 12
If No, go to Q. 13
12.Please provide the following details of the employment, business or partnership.
Name of business or partnership:.............................................
Number/Street:............................................................
Suburb/Town:........................State:.................P/Code:..............
Telephone Number:(....)....................................
Period of employment/involvement: ....../.../... to .../..../...
Number of hours worked per week: ................/week
Gross weekly earnings (i.e. before any deductions): $ ............./week
Your response to the following questions may help to alert Comcare to the need to instigate or amend your rehabilitation or return to work program.
13.Are you currently engaged in any voluntary work?
........
If Yes, go to Q. 14
If No, go to Q. 15
14.Please provide the following details of your voluntary work:
Name of organisation:........................................................
Number/Street:............................................................
Suburb/Town:.....................State:.................P/Code:..............
Telephone Number:(....)....................................
Period of involvement: .../.../... to .../..../...
Number of voluntary hours worked per week:.................../week
15.Have you engaged in any voluntary work at any time since you started receiving compensation?
........
If Yes, go to Q. 16
If No, go to Q. 17
16.Please provide the following details of your voluntary work.
Name of organisation:........................................................
Number/Street:..............................................................
Suburb/Town......................State:.................P/Code:..............
Telephone Number:(....)....................................
Period of involvement:..../....../...... to ....../..../...
Number of voluntary hours worked per week: .................../week
INCOME DETAILS
Non Employment Income
17.Do you receive a pension from a superannuation fund?
........
If Yes, go to Q. 18
If No, go to Q. 19
18.Please provide the following details of your pension:
Name of organisation: .......................................................
Number/Street:................................................................
Suburb/Town......................State:.............. P/Code:...........
Telephone No. (.....)........................
Date payments commencement: ....../....../......
What are your weekly payments? ......................./ week
19.Have you received a lump sum payment under a superannuation fund?
........
If Yes, go to Q. 20
If No, go to Q. 21
20.Please provide the following details of your superannuation fund.
Name of organisation: .......................................................
Number/Street:................................................................
Suburb/Town:...............................State:..............P/Code:...........
Telephone No. (.....)........................
Date lump sum received: ....../....../......
Amount of Lump sum payment: $.......................
21.Do you receive a pension or allowance from any other Commonwealth Department or Authority? (e.g. Social Security, Veterans' Affairs, etc.)
........
If Yes, go to Q. 22
If No, go to Q. 23
22.Please provide the following details of your pension or allowance:
Name of Department or Authority:.....................................
Number/Street:................................................................
Suburb/Town:......................State:.............. P/Code:...........
Telephone No. (.....)........................
Date payments commenced: ....../....../......
What are your weekly payments: ......................./ week
OTHER INCOME
23. Do you receive income from any other source not disclosed above, either from Non Employment Income (Benefits etc.) or from Employment Income (Wages)?
........
If Yes, go to Q. 24
If No, go to Q. 25
24.Please provide the following details of your income.
Name of paying Department or Employer:..............................
What type of payment:...............................................................
Date payments commenced: ....../....../......
Amount received per week: .........................
EDUCATION DETAILS
Your response to the following questions may help to alert Comcare to the need to instigate or amend your rehabilitation or return to work program.
25.Are you currently engaged in any part-time or full time study?
........
If Yes, go to Q. 26
If No, go to Q. 27
26.Please provide the following details of your study.
Name of Institution, Course and dates:....................................
Number/Street: ................................................................
Suburb/Town:.................... State:............. P/Code:..............
27.Have you ever engaged in any part-time or full time study since you started receiving compensation?
........
If Yes, go to Q. 28
If No, go to Q. 29
28.Please provide the following details of your study.
Name of Institution, Course and dates: ..........................................
Number/Street: ..................................................................
Suburb/Town:.................. State:............P/Code:...............
THIRD PARTY, COMMON LAW DETAILS
Comcare needs to be made aware of any payment to you for your injury under third party or common law action as it may affect your entitlement. This requirement is mandatory under the SRC Act 1988.
Your response to the following questions may help to alert Comcare to the need for recovery action.
29.Have you commenced common law proceedings against the Commonwealth, your employer or other responsible party as a result of your condition/ injury?
........
If Yes, go to Q. 30
If No, do not answer questions 30 –33, but go to next section.
30.Please provide the name, address and telephone number of your solicitor.
Name: .........................................................
Number/Street: ......................................................
Suburb/Town:.................. State:............P/Code:...............
Telephone: ...................................................
31.On what date were those proceedings commenced? .../.../...
32.Have you ever received any money as a result of those proceedings?
........
If Yes, go to Q. 33
If No, go to next section.
33.How much did you receive? $.......................
The information you provide on this form must be true and accurate. Any money paid by Comcare as a result of a false or misleading statement or claim will be recovered. People who commit, or attempt to commit, a fraudulent act against Comcare may be prosecuted under the Crimes Act 1914.
If any of your circumstances as detailed by you on this form change, or you intend to leave Australia for periods longer than three months, you MUST notify Comcare immediately.
DECLARATION
I declare that:
-
the information I have supplied on this form and any other attachment is true and accurate;
-
I am aware that the making of a false or misleading statement on this form may constitute a criminal offence under the Crimes Act 1914 for which I may be prosecuted;
-
I am aware that I must advise Comcare immediately if I receive any money from any other sources while receiving compensation payments, and
-
I am aware that I must advise Comcare immediately if my circumstances as listed on this form change.
ŸI have read and understand the information on the front of the periodic review form and consent to the release of my personal information to the parties listed in that notice.
Printed Name....................................................................
Signature............................................................................Date..................
Signature must be witnessed by an independent person (Not a spouse, partner or relative).
Printed Name .....................................................................
Signature of Witness............................................................Date..................
Address of Witness..........................................................................................
OA98/005 — 1 of 1