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 and fill them in so they are processed quickly. You can also electronically sign some of our forms. We have help available if you use assistive technology.

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.

Page last updated: 5 February 2024.
QC 65704