Notes for

Compensation and damages

Purpose of this form

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 1973.

Definition of a partner

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.

What you must tell us

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.

Are you receiving or

about to receive
compensation?

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 compensation.

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 compensation. 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 compensation.

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
compensation.
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
compensation.

Please keep these Notes (pages 1 to 4) for your information.

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Notes1 of 4

What if I receive a lump sum compensation payment?

We work out the period of time your payment coversthis 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 compensation.

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 compensation.
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?

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.

What to do before you

agree to accept a
compensation
payment

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
humanservices.gov.au/centrelinkcompensationrecovery

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.

www.

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
website humanservices.gov.au/centrelinkcompensationrecovery
www.

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 compensation.

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Notes2 of 4

Other help

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 132 300.

For more information

Go to our website humanservices.gov.au/business or call us on 132 850 or visit one of our Service
Centres for general information including compensation, or the Department of Social Services
website dss.gov.au for access to social security law and policy.
www.

www.

To speak to us in languages other than English, call 131 202.

Note: Call charges apply calls from mobile phones may be charged at a higher rate.

If you have a hearing

or speech impairment

TTY service Freecall 1800 810 586. A TTY phone is required to use this service.

Interpreters and
translations

If you need an interpreter or translation of any documents for our business, we can arrange this
for you free of charge.

What else you will

need to provide

This form tells you which other documents you need to provide.

Returning your form(s)

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.

www.

Mod(C).1403

For more information on how to access Online Services or how to lodge documents online, go to
humanservices.gov.au/submitdocumentsonline

Notes3 of 4

Information in other languages

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Notes4 of 4

MOD

Compensation and damages

Customer name
Date of birth

Contact
phone number

In whose name was this compensation claim made, or will be

made?
Mr

Mrs

Miss

Ms

Other

Family name

Please complete a separate Compensation and damages

form (Mod C) for you (or your partner) for each
compensation injury or claim.

First given name

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
compensation.

Second given name

Filling in this form

- Please use black or blue pen.
- Print in BLOCK LETTERS.
- Mark boxes like this
with a  or .

Go to 5 skip to the
- Where you see a box like this
question number shown. You do not need to answer
the questions in between.

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)?
No

Go to next question

Yes

Give details below

1 Other name

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 humanservices.gov.au/forms or contact
us.

Type of name (e.g. name at birth)

www.

Who has claimed, is claiming, or is eligible to claim the

compensation payment?

Your partner

The following questions must be completed by the person

claiming compensation or their authorised representative.

Please answer all the questions. If you do not answer all

the questions on this form, assessment of your Centrelink
entitlement may be delayed.

You

Your Centrelink Reference 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 1973.

Return this form online or to one of our Service Centres by

2 Other name

Go to next question
Your partner needs to complete and sign
the remaining questions about the claim
for compensation.

Type of name (e.g. maiden name)

Go to next question
Other

If you have more than 2 other names, attach a separate sheet

with details.

The following questions are to be

completed about the person claiming
compensation. This person or their
authorised representative (e.g. Centrelink
nominee, Power of Attorney) must sign
this form.

Go to next question
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CLK0Mod(C) 1403

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Compensation payers details

Name

What type of compensation has been or will be claimed?

Workers compensation
Motor Vehicle
Criminal Injuries/
Victims compensation

Address

Sporting injury
Public Liability
Medical Negligence

Postcode

Personal Accident and Sickness Insurance

or Income Replacement Insurance

Phone number
(

Other

Compensation payers claim number

What is the date of the injury or illness?

/

Attach a copy of supporting documentation.

10 Have regular compensation payments ever been paid?

What is the start date of the loss of earnings because of injury

or illness?
/

Give details
below

No

Yes

Go to next question

11 Have the payments stopped?

Where did the injury or illness occur?

No

At work

Yes

Travelling to or from work

Other

Go to 12

Go to next question
When did these payments stop?
/

Give details below

12 Are regular compensation payments being pursued?

8

No

In what state or territory did the injury or illness occur?

Yes

13 Has a lump sum compensation payment been paid?

No
Yes

Go to next question
What was the amount of the lump sum?
$
When was the lump sum paid?
/

Go to 15

14 Is a lump sum compensation payment being pursued?

Note: A separate Compensation and damages form (Mod C)
will have to be completed for each compensation injury or claim.
No
Yes

15 Have you made or intend to claim any other compensation

claims?
Note: A separate Compensation and damages form (Mod C)
will have to be completed for each compensation injury or claim.
No
Yes
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16 Do you, or did you have, a solicitor acting for you in this claim for

18

compensation?
No

Go to next question

Yes

Give details below

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.
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.

Name of solicitor

Name of solicitors firm

Address

www.

Postcode
Phone number
(

19 Statement
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.

17 Have you claimed or are you claiming compensation from an

employer?
Note: 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
compensation.
No

Go to next question

Yes

Give details below

Your signature

Employers business name

Date

Address

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.
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