This form contains 118 fields organized into 34 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
At-Work Injury Details
At work	Checkbox	Check this box if the injury or illness occurred while at work. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
At-work Injury Details	Text	Provide details about the injury or illness if it occurred at work. Fill only if 'At work' is 'Yes'. Depends on: At work
Employer's Business Name	Text	Enter the full business name of the employer where the injury or illness occurred. Fill only if 'At work' is 'Yes'. Depends on: At work
Employer's Street Address Line 1	Text	Enter the first line of the employer's street address. Fill only if 'At work' is 'Yes'. Depends on: At work
Employer's Street Address Line 2	Text	Enter the second line of the employer's street address. Fill only if 'At work' is 'Yes'. Depends on: At work
Employer's Suburb/City	Text	Enter the suburb or city of the employer's address. Fill only if 'At work' is 'Yes'. Depends on: At work
Employer's Postcode	Text	Enter the postcode of the employer's address. Fill only if 'At work' is 'Yes'. Max length: 4 characters Depends on: At work
Employer's Phone Number	Text	Enter the phone number of the employer, including the area code. Fill only if 'At work' is 'Yes'. Max length: 10 characters Depends on: At work
Attempt to Get Lump Sum Compensation Status
No	Checkbox	Check this box if you are not currently trying to get a lump sum compensation payment. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Yes	Checkbox	Check this box if you are currently trying to get a lump sum compensation payment. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Attempt to Get Periodic Compensation Status
No	Checkbox	Check this box if you are NOT currently trying to get periodic compensation payments. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Yes	Checkbox	Check this box if you ARE currently trying to get periodic compensation payments. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Checklist
Copy of your insurance policy	Checkbox	Check this box if you are providing a copy of your insurance policy related to Sporting injury, Personal Accident and Sickness Insurance and Income Protection Insurance, especially if required by question 13. Fill only if 'What type of compensation has been or will be claimed?' is 'Sporting injury', 'Personal Accident and Sickness Insurance' or 'Income Protection Insurance'. Depends on: Sporting injury, Personal Accident and Sickness Insurance or Income Protection Insurance
Letter of claim acceptance	Checkbox	Check this box if you are providing a copy of your letter of claim acceptance for other types of compensation.
Letter advising payments starting	Checkbox	Check this box if you are providing a copy of the letter advising when your compensation payments started.
Payslips/remittance advice (Centrelink payments)	Checkbox	Check this box if you are providing payslips or remittance advice for any periods you received Centrelink payments, as required by question 18. Fill only if 'When did periodic compensation payments start?' requires it. Depends on: Payment Start Date
Letter advising when payments stopped	Checkbox	Check this box if you are providing a copy of the letter advising when your compensation payments stopped, especially if you answered Yes at question 19. Fill only if 'Have the payments stopped?' is 'Yes'. Depends on: Yes
Signed settlement documents or letter (lump sum payment details)	Checkbox	Check this box if you are providing signed settlement documents or a letter advising the lump sum payment details, as required if you answered Yes at question 21. Fill only if 'Has a lump sum compensation payment been paid?' is 'Yes'. Depends on: Yes
Compensation and damages (Mod C) form	Checkbox	Check this box if you are providing the Compensation and damages (Mod C) form, especially if you answered Yes at question 23. Fill only if 'Have you made or intend to claim any other compensation claims?' is 'Yes'. Depends on: Yes
Compensation Claim Type
Sporting injury	Checkbox	Check this box if the compensation claim is for a sporting injury. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Personal Accident and Sickness Insurance or Income Protection Insurance	Checkbox	Check this box if the compensation claim is related to Personal Accident and Sickness Insurance or Income Protection Insurance. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Worker's compensation	Checkbox	Check this box if the compensation claim is for Worker's compensation. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Motor Vehicle	Checkbox	Check this box if the compensation claim is related to a motor vehicle incident. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Criminal Injuries/Victim's compensation	Checkbox	Check this box if the compensation claim is for criminal injuries or victim's compensation. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Public Liability	Checkbox	Check this box if the compensation claim is related to Public Liability. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Medical Negligence	Checkbox	Check this box if the compensation claim is related to Medical Negligence. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Other	Checkbox	Check this box if the compensation claim type is not listed above and provide details as requested. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Other Claim Type	Text	Enter the specific type of compensation claim if it falls under the 'Other' category. Fill only if 'Other' is 'Yes'. Depends on: Other
Claim Type Additional Details	Text	Provide additional information and details related to the compensation claim type. Fill only if 'Other' is 'Yes'. Depends on: Other
Compensation Payer Details
Compensation Payer Name	Text	Provide the full name of the compensation payer or insurance company. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Address Line 1	Text	Enter the first line of the compensation payer's address. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Address Line 2	Text	Enter the second line of the compensation payer's address. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Address Line 3	Text	Enter the third line of the compensation payer's address. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Postcode	Text	Provide the postcode for the compensation payer's address. Fill only if 'Who has received or claimed compensation?' is 'You'. Max length: 4 characters Depends on: You
Phone Number	Text	Enter the phone number of the compensation payer, including the area code. Fill only if 'Who has received or claimed compensation?' is 'You'. Max length: 10 characters Depends on: You
Claim Number	Text	Provide the compensation payer's claim number. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Compensation Payer Type
Australian insurer or individual	Checkbox	Check this box if the compensation payer or insurer is an Australian insurer or an Australian individual. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Overseas insurer or individual	Checkbox	Check this box if the compensation payer or insurer is an overseas insurer or an overseas individual. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Superannuation fund	Checkbox	Check this box if the compensation payer or insurer is a superannuation fund. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Do not know	Checkbox	Check this box if you do not know the type of compensation payer or insurer. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Compensation Recipient
You	Checkbox	Check this box if you have received or claimed compensation.
Your partner	Checkbox	Check this box if your partner has received or claimed compensation.
Date of Injury or Illness
Date of Injury or Illness	Date	Enter the date the injury occurred or when the illness was officially diagnosed. Fill only if 'Who has received or claimed compensation?' is 'You'. Max length: 10 characters Depends on: You
Declaration Date
Declaration Date	Date	Please enter the date you are completing this declaration. Max length: 10 characters
General
Instructions	Button
Instructions	Button
Q5GoToQ10	Button
DummyCalcQ17	Text
Q17GoToQ20	Button
Q19GoTo21	Button
Q26	Text	Max length: 1 characters
Digital Signature – On completion, insert digital signature or print and sign	Signature
Clear	Button
Injury Location
Australian Capital Territory	Checkbox	Check this box if the injury or illness occurred in the Australian Capital Territory. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
South Australia	Checkbox	Check this box if the injury or illness occurred in South Australia. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
New South Wales	Checkbox	Check this box if the injury or illness occurred in New South Wales. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Tasmania	Checkbox	Check this box if the injury or illness occurred in Tasmania. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Northern Territory	Checkbox	Check this box if the injury or illness occurred in the Northern Territory. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Victoria	Checkbox	Check this box if the injury or illness occurred in Victoria. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Queensland	Checkbox	Check this box if the injury or illness occurred in Queensland. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Western Australia	Checkbox	Check this box if the injury or illness occurred in Western Australia. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Outside Australia	Checkbox	Check this box if the injury or illness occurred outside Australia. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Outside Australia Location Details	Text	Please provide additional details about the location where the injury or illness occurred if it was outside Australia. Fill only if 'Outside Australia' is 'Yes'. Depends on: Outside Australia
Country of Injury/Illness	Text	Please enter the name of the country where the injury or illness occurred. Fill only if 'Outside Australia' is 'Yes'. Depends on: Outside Australia
Lump Sum Compensation Paid Status
No	Checkbox	Check this box if no lump sum compensation payment has been paid. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Yes	Checkbox	Check this box if a lump sum compensation payment has been paid. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Lump Sum Compensation Payment Details
Lump Sum Quantity	Number	Please provide the quantity associated with the lump sum compensation payment. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Gross Lump Sum Amount	Number	Please provide the gross amount of the lump sum compensation payment before tax. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Lump Sum Payment Date	Date	Please provide the date when the lump sum compensation payment was made. Fill only if 'Yes' is 'Yes'. Max length: 10 characters Depends on: Yes
Other Compensation Claims Status
No	Checkbox	Check this box if you have not made or do not intend to claim any other compensation. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Yes	Checkbox	Check this box if you have made or intend to claim any other compensation. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Other Injury Occurrence Details
Other	Checkbox	Check this box if the injury or illness occurred in a circumstance not listed as 'At work' or 'Travelling to or from work'. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Other Occurrence Details	Text	Provide additional details regarding how the injury or illness occurred, if not covered by the standard options. Fill only if 'Other' is 'Yes'. Depends on: Other
Partner's contact phone number
Partner's Contact Phone Number	Text	Provide your partner's contact phone number, including the area code. Max length: 10 characters
Partner's Customer Reference Number
Partner's Customer Reference Number Part 1	Text	Enter the first part of your partner's customer reference number. Max length: 3 characters
Partner's Customer Reference Number Part 2	Text	Enter the second part of your partner's customer reference number. Max length: 3 characters
Partner's Customer Reference Number Part 3	Text	Enter the third part of your partner's customer reference number. Max length: 3 characters
Partner's Customer Reference Number Part 4	Text	Enter the fourth part of your partner's customer reference number. Max length: 1 characters
Partner's Name
Partner's Family Name	Text	Please enter your partner's family name.
Partner's First Given Name	Text	Please enter your partner's first given name.
Partner's Second Given Name	Text	Please enter your partner's second given name.
Partner's Other Names Information
Q8_No	CheckBox
Q8	CheckBox
Partner's Other Name	Text	Provide one of your partner's other names, such as a name at birth, name before marriage, previous married name, Aboriginal or skin name, alias, adoptive name, or foster name. Fill only if 'Q8' is 'Yes'. Depends on: Q8
Partner's Other Names List	Text	Provide a detailed list of all other names your partner has been known by, or additional context for the names provided. Fill only if 'Q8' is 'Yes'. Depends on: Q8
Payment Cessation Date
Cessation Date Day	Text	Please provide the day of the month when the payments stopped. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Cessation Date Month Year	Date	Please provide the month and year when the payments stopped. Fill only if 'Yes' is 'Yes'. Max length: 10 characters Depends on: Yes
Payment Cessation Status
No	Checkbox	Check this box if the periodic compensation payments have not stopped. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Yes	Checkbox	Check this box if the periodic compensation payments have stopped. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Periodic Compensation Payment Details
Payment Start Date	Date	Please enter the date when periodic compensation payments began. Fill only if 'Yes' is 'Yes'. Max length: 10 characters Depends on: Yes
Gross Payment Amount	Number	Please enter the current periodic gross amount of the payment before tax. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Payment Frequency	Combobox	Please specify the frequency of the periodic gross amount (e.g., weekly, monthly, yearly). Fill only if 'Yes' is 'Yes'. Week Day Fortnight 4 Weeks 4 weeks Depends on: Yes
Periodic Compensation Payments Paid Status
No	Checkbox	Check this box if periodic compensation payments have not been paid. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Yes	Checkbox	Check this box if periodic compensation payments have been paid. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Solicitor Address
Solicitor Address Line 1	Text	Enter the first line of the solicitor's street address. Fill only if 'Yes (Solicitor)' is 'Yes'. Depends on: Yes (Solicitor)
Solicitor Address Line 2	Text	Enter the second line of the solicitor's street address. Fill only if 'Yes (Solicitor)' is 'Yes'. Depends on: Yes (Solicitor)
Solicitor Address Line 3	Text	Enter the third line of the solicitor's address, which may include the suburb, city, or state. Fill only if 'Yes (Solicitor)' is 'Yes'. Depends on: Yes (Solicitor)
Solicitor Postcode	Text	Enter the postcode for the solicitor's address. Fill only if 'Yes (Solicitor)' is 'Yes'. Max length: 4 characters Depends on: Yes (Solicitor)
Solicitor Details
Solicitor Details	Text	Provide any brief additional details regarding the solicitor. Fill only if 'Yes (Solicitor)' is 'Yes'. Depends on: Yes (Solicitor)
Solicitor Start Date	Date	Enter the date your solicitor started acting for you. Fill only if 'Yes (Solicitor)' is 'Yes'. Max length: 10 characters Depends on: Yes (Solicitor)
Solicitor Name	Text	Enter the full name of the solicitor acting for you. Fill only if 'Yes (Solicitor)' is 'Yes'. Depends on: Yes (Solicitor)
Solicitor's Firm Name	Text	Enter the full name of the solicitor's firm. Fill only if 'Yes (Solicitor)' is 'Yes'. Depends on: Yes (Solicitor)
Solicitor Phone Number
Solicitor Phone Number	Text	Provide the phone number of the solicitor, including the area code. Fill only if 'Yes (Solicitor)' is 'Yes'. Max length: 10 characters Depends on: Yes (Solicitor)
Solicitor Representation Status
No (Solicitor)	Checkbox	Check this box if you do not currently have, and have not had, a solicitor acting for you in this compensation claim. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Yes (Solicitor)	Checkbox	Check this box if you currently have, or have previously had, a solicitor acting for you in this compensation claim. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Start Date of Lost Wages
Same date as question 10	Checkbox	Check this box if the start date you lost wages due to the injury or illness is the same as the date entered for question 10. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Start Date of Lost Wages	Date	Provide the specific start date when wages were lost due to the injury or illness. Fill only if 'Same date as question 10' is 'No'. Max length: 10 characters Depends on: Same date as question 10
Travelling to or from Work Injury
Travelling to or from work	Checkbox	Check this box if the injury or illness occurred while you were travelling to or from work. Fill only if 'Who has received or claimed compensation?' is 'You'. Depends on: You
Your contact phone number
Contact Phone Number	Text	Please provide your full contact phone number, including the area code. Max length: 10 characters
Your Customer Reference Number
Customer Reference Number Part 1	Text	Please provide the first part of your customer reference number. Max length: 3 characters
Customer Reference Number Part 2	Text	Please provide the second part of your customer reference number. Max length: 3 characters
Customer Reference Number Part 3	Text	Please provide the third part of your customer reference number. Max length: 3 characters
Customer Reference Number Part 4	Text	Please provide the fourth part of your customer reference number. Max length: 1 characters
DummyCalcQ5	Text
Your date of birth
Date of Birth	Date	Please enter your date of birth. Max length: 10 characters
Your Name
Family Name	Text	Please provide your family name.
First Given Name	Text	Please provide your first given name.
Second Given Name	Text	Please provide your second given name.

Compensation and damages (Mod C) Instructions