D9182 Claim for compensation of Funeral Expenses and ...

More documents

Recommendations

Info

SECTION CClaimants Details13 Your full nameSurnameGiven name(s)Title Mr Mrs Miss Ms Other14 Home addressPOSTCODE15 Postal address(if same as home addresswrite “as above”)POSTCODE16 Contact details Home telephone [ ]Work telephone [ ]MobileFacsimile [ ]E-mail17 Method of contact to beused between DVA and theclaimantPlease indicate the methodof contact you prefer DVA usewhen communicating withyou.HomeWorkMobileE-mailLetterLegal representativeDVA will direct all communication to yourlegal representative only18 Date of birth / /19 Gender Male Female20 Relationship to deceased(e.g. partner, child, friend,funeral director).21 Do you have a Representativeacting for you on mattersrelating to this claim?(e.g. lawyer, ESO, Legacy).NoYesPlease ensure section E is completedD9182 11/13 P6 of 12
SECTION DDependants DetailsPlease:• detail below all dependants of the deceased. Where addresses and contact details are the same in section C write “asabove”;• ensure evidence relating to economic support as detailed in covering page is provided with claim;• if there is insufficient space use blank paper for further additional dependants;• ensure all dependant information is provided. Section 17(10) of the SRCA reads: Where claims for compensation under thissection are made by or on behalf of 2 or more dependants of a deceased employee, Comcare shall make one determinationin respect of those claims. Therefore no further dependant claims can be made at a later date.Dependant 122 Full nameIf the same as Claimantplease write “as per Claimantdetails”23 Home addressIf the same as Claimantplease write “as per Claimantdetails”24 Postal addressIf the same as Claimantplease write “as per Claimantdetails”Title Mr Mrs Miss Ms OtherSurnameGiven name(s)POSTCODEPOSTCODE25 Contact details Home telephone [ ]If the same as Claimantplease write “as per Claimant Work telephone [ ]details”MobileFacsimile [ ]E-mail26 Date of birthIf the same as Claimant/ /please write “as per Claimantdetails”27 Gender Male Female28 Relationship to deceased(e.g. partner, son, daughter).29 Was dependant 1 living withthe deceased immediatelybefore the date of death?NoPlease attach a copy of relevant information to verify relationship e.g. birth certificateYes30 Was dependant 1 dependenton the deceased foreconomic support at thedate of death?No Yes Wholly Mainly PartlyIf between the ages of 16 and 25 years, is this dependant a student?No Yes Full time Part timeD9182 11/13 P7 of 12
Page 1 and 2: Claim for Compensation for Funeral
Page 3 and 4: Privacy noticeThe information provi
Page 5: SECTION A continuedDECEASED’S PER
Page 9 and 10: SECTION D continuedDEPENDANTS DETAI
Page 11 and 12: SECTION GOther ClaimsFurther Lodgme

D9182 Claim for compensation of Funeral Expenses and ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?