COVID-19 Vaccine Claims Scheme cost calculation form (MO065)

Use this form to outline losses or expenses if you’re making a claim made under the COVID-19 Vaccine Claims Scheme.

Download and complete the COVID-19 Vaccine Claims Scheme expenses form.

Before you complete this form, you must check:

Find out more about the COVID-19 Vaccine Claims Scheme.

To fill in this form digitally you will need a computer and Adobe Acrobat Reader, or a similar program. You can download Adobe Acrobat Reader for free. If you can’t complete the form digitally, you can print it, complete it by hand and return it to us following the instructions on the form.

If you have a disability or impairment and use assistive technology, you may not be able to access our forms. If you can’t, please contact us. We can help you access, complete and submit them.

Page last updated: 2 April 2023.
QC 62401