Fields on page 1
This checklist
0
1
following
3
4
5
6
7
Don’t forget
Fields on page 4
No
Yes
related to this claim
Ex-Service Organisation
Legal
Full name
Organisation name (if applicable)
No
Yes
To what level
No
[
]
[
]
Mobile
[
]
Email address
DVA file number (if known)
Title (Mr, Mrs, Dr etc.)
28
Given name(s)
30
Residential address
32
POSTCODE
Postal address (if same as
35
POSTCODE
(
)
(
)
Mobile
Email address
Date of birth (dd/mm/yyyy)
Date of birth (dd/mm/yyyy)
45
Married
Single
Widowed
Divorced
De-facto
Fields on page 5
Next-of-kin’s name
Relationship to veteran
49
(
)
(
)
for disabilities that have not yet been
compensation payment for previously
No
Yes
In which State was the claim lodged? Year
Year lodged (if known)
No
Yes
Unit or (include Service number
Unit or branch of service Enlistment (include part-time reservist)
Enlistment and discharge dates (show actual dates, if known)
to
Nature of duties
Service number
reservist)
to
to
Nature of duties
71
72
to
to
to
76
77
to
to
to
81
82
to
to
to
Fields on page 6
Rank or Name of ship
Rank or grade
Name of owner or manager
Port of registration
Non-Australian ports visited
Voyage dates
From
93
94
95
96
97
To
From
No
Yes
What was the name
Disability 1
1
How do you believe your service caused, contributed to, or aggravated this disability
symptoms of the disability, or aggravation of the
Diagnosis
Diagnosis
Basis for diagnosis
How do you believe your service caused, contributed to, or aggravated this disability
When did the veteran first consult you for this condition
Fields on page 7
2
2
How do you believe your service caused, contributed to, or aggravated this disability
symptoms of the disability, or aggravation of the
Diagnosis
Diagnosis
Basis for diagnosis
Basis for diagnosis
When did the veteran first consult you for this condition
3
3
How do you believe your service caused, contributed to, or aggravated this disability
symptoms of the disability, or aggravation of the
Diagnosis
Diagnosis
Basis for diagnosis
Basis for diagnosis
When did the veteran first consult you for this condition
VRGP
Non VRGP
133
Fields on page 8
No
Yes
Cigarettes
Pipe
Cigars
Tobacco
No
Yes
Can’t remember
No
Yes
No
Yes
Can’t remember
disabilities have become worse.
Fields on page 9
Date of Disability treated
Date of treatment
Type of consultation Name of doctor/hospital etc.
Type of treatment or consultation provided (e.g. GP, specialist)
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
Local medical practioner’s name
Address
(
)
No
Date ceased work
Reason for ceasing work (e.g. age, illness, redundancy)
Yes
Name of current employer
How many hours per week do you
Fields on page 10
From (year)
180
Type of work
Name and address of employer
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
No
Yes
Please give details
Fields on page 11
No
Yes
Type of benefit or pension
Name and address of source
Reference Date of claim
Reference No. (if known)
211
212
213
214
215
216
217
218
219
220
221
222
No
Yes
Nature of injury or disease
Name and address of source
Reference Date of claim
Reference No. (if known)
228
229
230
231
232
233
234
235
Fields on page 12
No
Yes
your disability compensation
Branch
Address
Account in the name of
Account number
BSB number
Account type (e.g. savings)
Fields on page 13
under all Acts (VEA, DRCA and MRCA) that may be injury or disease which I am now claiming.
248
(please PRINT)
250
Fields on page 14
Full name
254
(
)
Work (
)
sign. This information will be evaluated by the delegate for
261
