Injury Benefit Application Form - IoMG Unified Scheme
Injury Benefit Application Form - IoMG Unified Scheme
Injury Benefit Application Form - IoMG Unified Scheme
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
Part 5 continuedTO BE SIGNED IN ALL CASESDamages or CompensationYou must carefully read the accompanying guidance in the attached ‘<strong>Injury</strong> <strong>Benefit</strong>s - Notes for Guidance’before signing this declaration.I declare that I have read the ‘Notes for Guidance’ and understand the following:I cannot receive all of my damages or compensation recovered from any source (such as Criminal Injuries Compensation<strong>Scheme</strong>) for the same injury and all of my <strong>Injury</strong> <strong>Benefit</strong>s. If I am entitled to <strong>Injury</strong> <strong>Benefit</strong>s, the PSPA will offset from my<strong>Injury</strong> <strong>Benefit</strong>s any (meaning ‘all’) damages or compensation recovered for the same injury as I am claiming for here.Only where a loss of earnings element is clearly identifiable and delineated in the settlement the PSPA may, in certaincircumstances, limit the amount to be offset to that amount.This means that:If I have already recovered damages or compensation before making this claim I must tell the PSPA on this claim form sothat my <strong>Injury</strong> <strong>Benefit</strong>s can be adjusted (reduced) from the outset to take into account the damages or compensation. Iam aware that depending on the amounts involved, this could result in me not being entitled to any <strong>Injury</strong> <strong>Benefit</strong>spayments.If I recover damages or compensation in respect of the same injury as I am claiming here after I have made this claim butbefore any payment is made, I must tell the PSPA immediately so that my <strong>Injury</strong> <strong>Benefit</strong>s can be adjusted (reduced) fromthe outset to take into account the damages or compensation. I am aware that depending on the amounts involved, thiscould result in me not being entitled to any <strong>Injury</strong> <strong>Benefit</strong>s payments.If I have made a claim for damages or compensation but it has not been settled by the time my <strong>Injury</strong> <strong>Benefit</strong>s can bepaid, PSPA will pay me any award I am entitled to on account and on the clear understanding that I must notify them ofthe details within 14 days of the settlement and that, depending on the amounts involved, when the offset is calculated Iwill have to repay some or all of the <strong>Injury</strong> <strong>Benefit</strong>s I have been paid and my allowance will be either reduced or stopped.Signature:Date:7. Are you a member of a Personal No: Yes:or Private pension scheme?Policy Reference Number:Name and Address of <strong>Scheme</strong>:
Change language