Oscf PDF

ONLINE LODGEMENT – MYACCOUNT
Claim for Compensation
About this claim

The online claim for compensation for injury or disease is for use by veterans (including Australian merchant
mariners), serving or former members of the Australian Defence Force (ADF), reservists, cadets, declared
members, members of a peacekeeping force and others (such as members of philanthropic organisations).
Claim Type
 Lodge a claim for liability for Injury or Disease
This claim is submitted to:  Apply for treatment under Non-Liability Health care
treatment arrangements
Personal Details
Your full name Mr STEVEN J TASKIN
Department of Veterans’ Affairs

VSM10150
(DVA File number)
Have you ever been known by any

No
other names?
Gender Male
Date of birth 25/04/1967
Relationship status Separated
Residential address 44 WARRAK DR, BANNOCKBURN, 3331, VIC, Australia
Postal address 44 WARRAK DR, BANNOCKBURN, 3331, VIC, Australia
Phone and email Home Work
Mobile Fax
61-0438900131
Email
steventaskin@live.co.au
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Mr STEVEN J TASKIN – File Number:VSM10150 – Lodgement Status:DRAFT Claim Summary -Page 1 of 9
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Service Details
Details of your service including where you served are required in order to help determine your injury or
disease claim.
Have you served in the Australian

Yes
Defence Force?
Current or last unit name 26 Tpt Sqn
Periods of service
Service Arm Service type Highest PMKeyS Service Enlistment Discharge Discharge
rank number number date date reason
Army Permanent Private 8246685 07/02/1995 30/03/2003 Administrat
Force ive
Mr STEVEN J TASKIN – File Number: VSM10150 – Lodgement Status: DRAFT Claim Summary - Page 2 of 9
Did you serve outside Australia? Yes
Service included the following regions:

 EAST TIMOR (UNMISET) (OPERATION CITADEL)
Did you serve with the Australian

Police Contingent of a United No
Nations Peacekeeping Mission?
Have you served under another

No
name?
Please provide any relevant service

 Not provided
documents you have
Medical Practitioner Details
Do you have a current medical Yes
practitioner?
Medical practitioner’s name
DR Margaret Somerville
Medical practitioner’s address

Bannockburn Surgery, 16 High street, Bannockburn, 3331, VIC,
Australia
Daytime phone Mobile phone
61-03-52811481
Fax
Medical Information - Condition 1
In this section you need to provide information for the injury or disease you are claiming.
Injury or disease name Disc Degeneration Causing Discovering Back Pain
When did you first become aware of

08/09/1995
the signs or symptoms?
Did the condition result from a

specific event or incident that Yes
occurred during your service?
What was the date of the event or

08/09/1995
incident?
Service period during which the

incident that caused the injury or Service within Australia
disease occurred
Were you on duty at the time of the

Yes
incident?
How do you believe your service

caused, contributed to or Lifting rubber off the back of ute
aggravated this injury or disease?
Who is the treating medical

practitioner/hospital/specialist for General Practitioner (GP) already provided
this condition?
Has the condition been confirmed
Yes
by a doctor?
Diagnosis details provided Not provided
From the information provided your claim will be considered under the following Act(s):

Safety Rehabilitation and Compensation (Defence-related Claims) Act 1988


Entitlement under other Acts

I understand that it may become evident to DVA during the investigation of this claim that I may have
entitlement under one or more Acts (VEA, DRCA or MRCA) instead of, or in addition to, the Act/s identified
above. If this occurs, I wish for DVA to consider that entitlement.
Non-Liability Health Care
Health care can be provided to veterans and members for certain medical conditions even though they
were not caused by service.
Please indicate if you have been diagnosed with and/or wish to apply for health care from DVA for any of
the following conditions (including any that you are also claiming liability for on this claim):
Condition details
Condition 1
Condition name
Mental Health Condition
Other Claims and Payments
Why is this information collected?
Your entitlement to benefits for injury or disease can be impacted by other claims or payments that you
receive from DVA or other agencies.
Are you receiving, or have received

in the past two years, benefits from Yes
DVA?
Are you already receiving, have you

previously received, or have you
applied for any payments from No
agencies other than DVA for your
claimed injuries or diseases?
If you lodge a claim for any other pension, benefit or allowance while this claim is being processed or after
liability is accepted, you MUST advise DVA.
Other than making this claim have

you or do you intend to take legal
action to recover personal injury
damages or compensation from No
either a government agency or
department or a third party for the
claimed injuries or diseases?
If you take legal action, you must notify DVA in writing as soon as practicable but no later than 7 days after the
day on which you make the claim. You must also notify DVA in writing within 28 days of recovering any
damages whether they be in the form of a ruling or settlement of claim. These time periods are a legislative
requirement.
Veteran Payment Details
If you are claiming for a mental health condition, are currently unable to work more than eight
hours per week and require financial assistance, you may be eligible for Veteran Payment.
Veteran Payment provides financial assistance while your liability claim for a mental health condition is
determined. For further information, see Factsheet IS189 – Veteran Payment Overview.
Would you like DVA to assess your

eligibility for Veteran Payment? No
Authorisations and declarations
I authorise DVA to obtain information and/or reports from medical practitioners, hospitals, clinics, insurance companies,
Commonwealth Departments or Agencies, or other organisations in relation to this claim or its review.
I agree that DVA may request from the Department of Defence information about my full service and medical history so that a
comprehensive assessment of eligibility may be undertaken.
I agree that DVA may use personal information about me and disclose that information to other agencies and bodies, where DVA
or those other agencies or bodies have a legitimate interest in such personal information (refer to the list of Organisations below)
I authorise the Nominated Claim Representative, if provided, to represent me in respect of this claim and any review of a decision
relating to this claim. This authorisation includes access to my personal information for purposes related to this claim and will
continue until I:
 revoke the authorisation; or
 nominate another representative to represent me.
I declare that:
 The information I have provided in this application and on any other attachments is true and accurate;
 I am aware that I must advise DVA:
- immediately if I engage in any employment (whether paid, unpaid or voluntary) or if I engage in running a business in my
own right or as a partner during any period when I am medically certified to be unfit for work due to the injury or disease
to which this claim for compensation relates; or
- immediately if, during any period of certified incapacity for work, my injury or disease improves sufficiently to allow me to
return to work; or
- if I receive any monies by way of third party damages or other compensation mechanism for any injury or disease; or
- if I lodge a claim for any other pension, benefit or allowance while this claim is being processed.
 I am aware that any compensation monies which I may be paid as a result of any false or misleading claim or statement
will be recovered by DVA;
 I am aware that a copy of this claim form may be sent to the Department of Defence where authorised by legislation.
 I am aware that there are penalties for making false statements.
Organisations we share information with

The information provided in this claim may also be provided to another agency or body for their lawful purposes. These agencies
or bodies include:
 the Repatriation Commission;
 the Military Rehabilitation and Compensation Commission;
 the Department of Defence (including a serving member’s Service Chief);
 the Department of Human Services;
 the Australian Tax Office;
 other State or Territory authorities to verify your eligibility for rebates or concessions relating to rates, electricity, transport,
motor vehicles and ambulance;
 the legal representative of the Department of Defence in relation to any common law (third party) damages action;
 ComSuper (regarding any Commonwealth superannuation entitlement you may have);
 Commonwealth, State and Territory workers’ compensation authorities in relation to a similar injury or disease;
 doctors, hospitals and other health care professionals who have provided you with the treatment or who are requested to
assist in the investigation of your claim;
 your current and/or previous employer(s).
 I have read and agree to the Authorisation and Declaration information.

 I understand that once I press Lodge claim that I will no longer be able to edit or modify this claim online.
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ONLINE LODGEMENT – MYACCOUNT

Claim for Compensation

About this claim

Department of Veterans’ Affairs

Have you ever been known by any

Date of birth 25/04/1967

Relationship status Separated

Residential address 44 WARRAK DR, BANNOCKBURN, 3331, VIC, Australia

Postal address 44 WARRAK DR, BANNOCKBURN, 3331, VIC, Australia

Phone and email Home Work

Have you served in the Australian

Current or last unit name 26 Tpt Sqn

Service included the following regions:

Did you serve with the Australian

Have you served under another

Please provide any relevant service

Medical practitioner’s address

Injury or disease name Disc Degeneration Causing Discovering Back Pain

When did you first become aware of

Did the condition result from a

What was the date of the event or

Service period during which the

Were you on duty at the time of the

How do you believe your service

Who is the treating medical

Diagnosis details provided Not provided

Safety Rehabilitation and Compensation (Defence-related Claims) Act 1988

Entitlement under other Acts

Are you receiving, or have received

Are you already receiving, have you

Other than making this claim have

Would you like DVA to assess your

Organisations we share information with

 I have read and agree to the Authorisation and Declaration information.

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