D9182 Claim for compensation of Funeral Expenses and ...

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SECTION ERepresentation51 Representative detailsTitle Mr Mrs Miss Ms OtherSurnameGiven name(s)52 Name of organisation(if applicable)52 AddressPOSTCODE53 Contact details Work telephone [ ]Home telephone [ ]MobileFacsimile [ ]E-mailYour Representative must also sign this form at Section ISECTION FLegal ActionIntention54 Have you or do you intend totake action, other thanmaking this claim, to recoverdamages or expenses?NoYesPlease provide the name and contact details of your legal representativeImportant: You must inform us if you take legal action at a later date or get any money fordamages. There are penalties if you do not inform us within 7 days ofcommencing legal action in respect of death.D9182 11/13 P10 of 12
SECTION GOther ClaimsFurther Lodgment55 Have you or do you intendlodging a claim for a pensionunder the provisions of theVeterans’ Entitlements Act1986 (VEA)?No Yes If you have already lodged a claim under the VEA or MRCA please providethe DVA file numberImportant: Posthumous claim for Permanent Impairment compensation may only be madeby your Legal Personal Representative.SECTION HFuneral ExpensesPersons who have paid the cost of the funeral or who carried out the funeral (where that cost has not been paid) of a memberor former member of the Australian Defence Force (ADF) where the person died as a result of a pre 1 July 2004 defence-relatedinjury or disease should complete this section. Please be aware that where the answer to question 7 is no, liability will needto be established prior to any reimbursement of funeral expenses being made.Details of the funeral56 Funeral Director’s name57 Date of funeral/ /58 Location of funeral59 Have the funeralexpenses for thedeceased (referred toin Section A of thisclaim) been paid?No Yes Name of person/organisation who paid the expensesAmount of funeral expenses$Date paid/ /Method of paymentPlease attach a copy of relevant documentation e.g. tax invoice, receipt, etc.D9182 11/13 P11 of 12
Page 1 and 2: Claim for Compensation for Funeral
Page 3 and 4: Privacy noticeThe information provi
Page 5 and 6: SECTION A continuedDECEASED’S PER
Page 7 and 8: SECTION DDependants DetailsPlease:
Page 9: SECTION D continuedDEPENDANTS DETAI

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