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.

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

Before you complete this form, you must check:

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

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 use self service, request someone to deal with us on your behalf, or contact us. We can help you access, complete and submit them.

Page last updated: 5 February 2024.
QC 65704