COVID-19 Vaccine Claims Scheme – Third Party Payment Statement form (MO066)

Use this form to declare if you have, have not, or will receive third party payments for claim losses you are applying for under the COVID-19 Vaccine Claims Scheme.

You must download our forms to fill them in. We have help available if you use assistive technology or if you need a translator or interpreter. Find out how to use our forms.

Download and complete the COVID-19 Vaccine Claims Scheme – third party payment statement.

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Find out more about the COVID-19 Vaccine Claims Scheme and third party payments.

Page last updated: 7 June 2025.
QC 65704