S3 O SETTLEMENT APPLICATION FORM SETTLEMENT APPLICATION FORM [FOR

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S3 O: Settlement Application Form

S3 O: Settlement Application Form





SETTLEMENT APPLICATION FORM
[for Subdivision 3 workers]

………………………………

………………………………

……………………………… [Agent’s name and address]

………………………………

I ……..….………………………………………………………………………..…. [print name of worker]

of ….….…..……………………………………………………………………………………………………

…………………………………………………………….…………………………… [address of worker]

am applying for a lump sum settlement under Subdivision 3 of Division 3A of Part 4 of the Accident Compensation Act 1985 (the Act).

My claim number with the Victorian WorkCover Authority is …………………………..………. [insert claim number]

I received a written response from ………………………………………………… [insert Agent name] under section 119B of the Act in respect of my expression of interest on ….. ……………………….. [insert date].

I lodged my expression of interest to ………………………………..……………. [insert Agent name] on ……………….…. [insert date].

I attach certificates from my legal and financial advisers as required by the Ministerial Directions issued under section 119L of the Act.

Signed by …………………………………………………………………

Date ……………………………

THIS FORM SHOULD BE POSTED TO YOUR WORKCOVER AGENT BY REGISTERED POST OR ELSE BE HAND DELIVERED.



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