Fillable AFCSWPS0001 - Online Version AFCSWPS0001 claim form

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AFCSWPS0001 - Online Version AFCSWPS0001 claim form

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AFCSWPS0001
Veterans UK
Armed Forces Compensation Scheme
and War Pensions Scheme
Claim Form and notes about how to claim
This form should be completed if you want to make a claim for an injury or illness you think has
been caused by your service in HM Armed Forces. You can also claim for conditions you had
before service - where you feel your service made them worse.
What you need to do
• Before completing this form read the information notes carefully.
• Please read all of the questions carefully and make sure you give full answers.
• Send copies of any medical or other information you already have that tells us about
your condition. Providing as much information as possible may speed up the decision on
your claim. We tell you which types of information we find helpful in the notes section.
We don’t need you to get any new or specially prepared information and we can’t
refund any costs involved if you do this.
UK Special Forces (UKSF)
Any claimant who has served or is serving
with UKSF must contact the Disclosure
Cell prior to completing this form.
If you served after 1996 you will be subject
to the Confidentiality Contract.
• You must apply for Express Prior
Authority in Writing (EPAW) through
the Disclosure Cell before putting in
any claim which may disclose details
of your service with UKSF or any
units directly supporting them.
Where to send the completed form
Please send the completed form and any
supporting documents to:
Veterans UK
Norcross
Thornton-Cleveleys
Lancashire
FY5 3WP
England
Please return the completed form as soon
as you can as a delay may result in
payment from a later date.
We cannot accept claim forms
returned by email, or without a
signature.
EPAW obtained
or requested?
Yes No
If obtained then provide:
Reference
number
Date
Click here for instructions on how to
apply for EPAW.
Any declaration of UKSF service will be
checked and verified.
01/20
2
AFCSWPS0001
Please fill in this claim form and send it back to us as soon as you can
Part 1 About you
1. Title – for example Mr, Mrs,
Miss, Ms
2.
Surname or family name
3.
All other names in full
4.
Contact address
Important – You must tell us if
your address or contact numbers
change
Postcode
5. Daytime phone number – please
include area code
Mobile number if different to
number above
6.
Date of birth (dd/mm/yyyy)
Letters
Numbers
Letter
7.
National Insurance number
8. Have you previously made a
claim under the WPS or AFCS?
Yes
No
If yes, please tell us your reference number
9. Which Armed Forces Pension
Schemes are you a member of?
1975 2005 2015
None Other
10. Have you received an AFCS
Fast Payment?
Yes No
i
Before you fill in this form, click here to read the information notes
i
B
ef
ore
y
ou
ans
w
er
Q
10,
c
lick here to read page 3 of the information notes
3
AFCSWPS0001
Part 2 Service details
1
st
Period of service
2
nd
Period of service
11. Name in service (if different to
Part 1)
12.
Service number
13. Service branch (RN, Army, RAF,
RM or the Polish equivalent)
14. Service type (Regular, Reserve,
Gurkha)
15. Current rank if serving or rank
on discharge
16.
What is/was your trade?
17.
Date of enlistment
18.
Date of discharge
19. Reason for discharge (if
appropriate)
20. Address of your current/last
Service Unit
Postcode
If you have more than 2 periods of service please
continue at Part 7 - Extra Information
4
AFCSWPS0001
Part 3 - Your claim
A - Please list details of your conditions/injuries/illnesses in the table below:
You must make it clear which side of the body the injury relates to, for example left
leg, right arm.
Condition/Injury/
Illness you are
claiming
Medically
confirmed
diagnosis if known
Onset date of
condition/
injury/illness
Please explain why you feel it was
caused by service
Example
Broken left arm Fractured left
radius
01/12/2010 Moving boxes in store room and a
box of supplies fell on my left arm.
If you need more space to tell us about your conditions/injuries/illnesses, please
continue at Part 7 - Extra Information
5
AFCSWPS0001
Part 3 - continued
B - For a specific incident or accident:
21. What was the date of the
incident/accident?
22. Where were you when you were
injured?
EPAW applies for UKSF
23. What were you doing at the
time?
EPAW applies for UKSF
24. Did you report the injury?
Yes No
If yes, who did you report it to?
25. Were you in an acting rank at
the time?
Yes No
If yes, what rank?
26. Did you complete an accident
report form?
Send us a copy if you have
one
Yes No
Date reported (dd/mm/yyyy)
C - For Road Traffic Accidents also tell us:
27.
Reasons for the journey
28. The route you took from start to
final destination
6
AFCSWPS0001
Part 3 - continued
29. Were you on authorised leave at
the time?
Yes No
30. Details of any police
involvement
31. Details of any
witnesses/passengers
D - For sporting activity, adventure training or physical training injuries also tell us:
32.
What was the activity?
33. Was it organised/authorised by
the armed forces?
Yes No
34. Were you representing your
unit?
Yes No
If you have them, please send copies of: Part 1 orders, Admin Instructions,
Authorisation Papers.
35.
Details of any witnesses
36. Details of any treatment given at
the time of the injury
7
AFCSWPS0001
Part 3 - continued
E -
If you are claiming for a condition, injury or illness which you feel started over
a period of time, rather than as a result of a specific incident/event, tell us:
37. When it started
(if unknown, then approx. date)
38. Do you think the injury/illness
was due to any of the following?
Trade Duties Training
Exposure to Cold Heat Noise
Vibration
Chemical, biological or
hazardous substances
If exposure to chemical,
biological or hazardous
substances, what were they?
39. Date you first took part in the
above or were exposed
40. Length of time involved or
exposed
41. When did you first seek medical
attention?
F – Downgrading
42.
Were you downgraded for any of
the conditions claimed at Part A
page 4?
Yes No
If yes, please tell us:
From
To
Date
Category
If you need more space
, please continue at Part 7 – Extra Information
8
AFCSWPS0001
Part 4 Medical and Treatment
Name
43. Who did you first seek medical
attention from?
Address
Postcode
Telephone number including area code
44. What specific medical diagnosis
have you been given?
45. Which medical practitioner gave
this diagnosis? (By this we mean
your Medical Officer, GP,
Hospital or other practitioner)
Name
Address
Postcode
Contact telephone number including area code
9
AFCSWPS0001
Part 4 - continued
46. Please give details of any hospital treatment you have received for your injury or illness
either during or after service.
Injury or illness treated
Injury or illness treated
Name of consultant or clinic
Name of consultant or clinic
Hospital name and address
Hospital name and address
Postcode
Postcode
Hospital record number
Hospital record number
Treatment Dates
Treatment Dates
Start
End
Start
End
If you need more space
, please continue at Part 7 – Extra Information
10
AFCSWPS0001
Part 4 - continued
47. Are you on a waiting list for
surgery for the condition/
injury/illness you are claiming?
Yes No
48.
When is this due to take place?
49. Please tell us the name and
address of the hospital where
this is due to take place
Postcode
50. Are you waiting for or have you
received any other type of
treatment for the condition/
injury/illness you are claiming?
Yes No
51. What is/was the type of
treatment?
52. Please provide the full address
of where you had this treatment
Postcode
53. What is the name and address
of your current Medical Officer or
GP?
Name
Address
Postcode
Telephone number including area code
11
AFCSWPS0001
Part 5 – Other compensation
54. Are you claiming for or have you
received compensation from the
MOD for criminal injuries or for
civil negligence, or
compensation from civil
authorities in Great Britain and
Northern Ireland for criminal
injuries?
Yes No
55. What condition(s) are you
claiming, or have claimed,
compensation for?
56. What was the outcome of your
claim? (Please include any
reference numbers and details
of the person or organisation)
57. Please tell us the amount of any
payment you received
58.
What type of payment was this? Interim settlement Final settlement
59. When did you receive this
payment?
60. If a solicitor has helped you with
your claim for other
compensation, please tell us
their details
Name
Address
Postcode
Telephone number including area code
i
For
f
urt
her
in
for
m
atio
n, click here to read page 3 of the information notes
12
AFCSWPS0001
Part 6 About other benefits, allowances or entitlement
Payments from both the Armed Forces Compensation Scheme and the War Pension Scheme
may affect related benefits from the Department for Work and Pensions (DWP).
It is your responsibility to inform the relevant Benefit Office, local authority, or Tax
Credit Office if you receive payments under one of the schemes.
61. Are you receiving any of the following:
Date claim made
Personal Independence Payment (PIP) or Disability
Living Allowance (DLA)
Date claim made
I
ncome Support
Date claim made
Universal Credit
Date claim made
Income–related Employment and Support Allowance
(ESA)
Date claim made
Income
–related Job Seekers Allowance (JSA)
Date claim made
Tax Credits paid to you or your family
Date claim made
Housing Benefit and Council Tax Benefit
Date claim made
I
ndustrial Injuries Disablement Benefit (IIDB)
62. Please tell us all the condition(s) you claimed or are getting IIDB for:
63. If you have received payment under any of the following schemes, tell us the date you were
paid and the amount.
Date
Amount
Diffuse Mesothelioma 2014 Scheme
Diffuse Mesothelioma 2008 Scheme
The Workers Compensation 1979
Pneumoconiosis Act
13
AFCSWPS0001
Part 7 – Extra Information
14
AFCSWPS0001
Part 8 – Your payment details
Serving Personnel
Payments under the AFCS – For serving personnel, payment will be made into the same
account as your pay. If you have any salary splitting instructions in place then you will
need to review this.
All Ex
-Service Personnel
Payment will be made directly into a bank, building society or other account. Many banks and
building societies will let you collect cash at the post office.
Please indicate the payment frequency you want:
Monthly - officers Quarterly – officers
4 weekly – other
ranks
13 weekly – other
ranks
Weekly – other ranks
Please provide details of the account you want to use. This can be:
• An account in your name.
• A joint account.
• Someone else’s account, subject to the terms and conditions of the account, and as
long as you have the other person’s permission and authorise them to use the money in
the way you tell them.
•
A credit union account.
Please note: if you are an Appointee or legal representative acting on behalf of a customer the
account should be in your name.
Important – You must tell us if your account details change.
Full name of bank, building society or other account provider
Name of the account holder exactly as it is shown on the cheque book, bank card or
statement
Sort code – Please tell us all 6
numbers e.g. 12-34-56
Account number – Most account
numbers are 8 numbers long. If your
account has fewer than 10 numbers,
please fill in the number from the left.
If you are using a building society account, you may need to tell us a roll or reference number.
This may be made up of letters and numbers and may be up to 18 characters long. If you are
not sure if the account has a roll or reference number, please ask the building society.
Building society roll or reference number
15
AFCSWPS0001
Part 8 - continued
Accounts outside the UK
See your overseas bank statement or ask your bank for the information we need
If you want us to make payments to an account that is outside the UK, we will need the
following details:
International Bank Account Number (IBAN)
Business Identifier Code (BIC)
If you want us to make payments to an account that is outside the UK, and is not in the Single
European Payments Area (SEPA), we will need any of the following details that apply:
Name and Address of the Bank
Swift
Bank/Branch Code (BSB code)
Transit Routing Number
Type of Account, e.g. Saving/
Checking
16
AFCSWPS0001
Part 9 - Consent for Email Correspondence
Veterans UK is happy to conduct correspondence with customers using a nominated email
address if that is their preference. There are some types of personal information we would not
be able to include in email correspondence. Please read the information below.
I authorise Veterans UK to use email whenever possible in its correspondence with me using
my nominated email address shown below. I accept that information including bank account
details, National Insurance Numbers, medical details and any other information that could
compromise my identity will not be included in emails.
I understand that correspondence transmitted by email may be open to abuse because it is
transmitted over an unsecured network. I accept that the MOD will not be liable for any loss,
interception or unauthorised use of information transmitted this way.
Do you wish to correspond by email?
Yes
No
Your email address
Signature
Date
We cannot accept claim forms by email
PLEASE REMEMBER TO SIGN AND DATE
PART 11 - DECLARATION ON PAGE 18
Part 10 – How the MOD collects and uses personal information
The Ministry of Defence (MOD) is committed to protecting the privacy and security of your
personal information and ensuring that all your personal data is processed in accordance with
UK data protection legislation. The MOD Personal information charter contains the standards
you can expect when we ask for, hold or share your personal information and your rights under
the UK data protection legislation.
Further information can be found here on the way the Veterans UK processes your data in line with the charter
i
For further information, click here to read page 4 of the information notes
Please sign the form here in pen after
printing
17
AFCSWPS0001
Part 1
1
– Declaration
I confirm that if I have signed a UKSF Confidentiality Contract, I have been careful not to
make unauthorised disclosures. I have sought a
dvice from the Disclosure Cell and
have
EPAW to make such statements.
I confirm the information I have given is accurate and complete to the best of my knowledge
and belief.
I unde
rstand that the information and personal data I have provided on this form, and any
information and personal data I provide subsequently may be:
• Used by the MOD in connection with my claim, or any subsequent reconsideration,
review or appeal, under the Armed Forces Compensation Scheme (AFCS) or the
Service Pensions Order (SPO) or any other schemes administered by Veterans UK.
• Passed to any organisation contracted to provide medical services to the MOD and any
qualified medical practitioner asked by the MOD to provide specialist advice
• Passed to the DWP.
• Used by the MOD and its agents in connection with all matters relating to this or future
claims, or any subsequent reconsideration, review or appeal, under the AFCS or the
SPO or other schemes administered by Veterans UK, and other claims against the
MOD, and by other Government Departments, which have a legitimate interest in this
information, for example, for the prevention and detection of crime.
I understand that
• I must immediately tell the MOD of anything that may affect my entitlement to, or the
amount of, an award under the AFCS, a war pension, a supplementary allowance or any
survivors’ benefits paid under the SPO, or an award paid under any other scheme
administered by Veterans UK, including any changes of address.
• If I knowingly give false information, I may be liable to prosecution.
In order to process your application
• The MOD and,
• any doctor advising the MOD and,
• any organisation contracted to provide medical services to the MOD and any doctor
providing services to that organisation.
maybe required to contact
• any doctor who has provided treatment and,
• any hospital or similar place and,
• anyone else who has provided investigation or treatment (such as a physiotherapist)
f
or copies of all medical records (including those in sealed envelopes) and any other
information required to consider my claim, or any subsequent reconsideration, review or
appeal, under the AFCS or
the SPO or any other schemes administered by Veterans UK.
18
AFCSWPS0001
Part 1
1
- continued
And that the MOD may
• Disclose medical records, and any information about my claim, or any subsequent
reconsideration, review or appeal, under the AFCS or the SPO or any other schemes
administered by Veterans UK, to any organisation contracted to provide medical
services to the MOD and any qualified medical practitioner or consultant asked by the
MOD to provide specialist advice. I also agree that the MOD may send copies of
medical information obtained for the purposes of my claim, or any subsequent
reconsideration, review or appeal, under the AFCS or the SPO or any other schemes
administered by Veterans UK to my General Practitioner. I understand that the
information will be retained by the MOD, either as a written record, or on a secure
database, and may be used in future if it is necessary to reconsider or review my claim
and any award made.
I agree
• To repay any sum paid as a result of this claim in the event that an overpayment is
made for any reason.
Please remember you must sign this form yourself if you can – even if someone else
has filled it in for you. If a representative who acts as power of attorney or appointee for
the
claimant is signing this form, they must enclose evidence to show that they are the
legal representative.
Signature
Date
Name
U
nsigned forms will be returned. This will delay your claim and could affect
any payment you may be entitled to.
Please sign the form here in pen after
printing
19
AFCSWPS0001
Part 1
2
- What to do now
Please check
• You have answered all the questions on this form that apply to you. Failure to answer all
the required questions may affect the time taken to deal with your claim.
• You have provided any additional evidence or information that you feel will help us to
understand how your health condition, injury or illness affects you, or how it was caused
by service.
Checklist
Have you included full details of your current GP at page 10?
Have you completed Part 9 - Consent for Email Correspondence at page 16?
Have you signed and dated the declaration at page 18?
Have you put your name and National Insurance Number at the top of any
documents or extra pieces of paper you are sending?
Please list all the documents you are sending with this claim form. For example
Accident Report forms, current prescription list.
Important – Tell us the address
you want any original documents
returned to, if different to the
contact address at Q4.
Address
Postcode
Send the claim form and any extra documents to the address on page 1
Part 1
3
– What happens next
i
For information on what happens next, click here to read page 4 of the information notes
20
AFCSWPS0001
Part 14
– For completion by Veterans Welfare Service (VWS) or
Authorised Agent only
Name of Department or Organisation
Signature
Your reference number
Official address stamp
Date of receipt of claimant’s first contact
with the VWS or ‘Authorised Agent’ about
this claim
Date claim form issued
Date completed claim form was received
back by the VWS or the ‘Authorised Agent’
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Completed 2 June 2020

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