You’re offline. This is a read only version of the page.
Skip to main content
| Department of Health
Toggle navigation
Home
Covid 19 Notice of Claim Form
Search
Sign in
Home
Covid 19 Notice of Claim Form
First Name
*
*
Last Name
*
*
Your address
*
Your telephone number
*
Gender
Male
Female
Other
Prefer not to say
Unknown
Your date of birth
*
Tenancy Reference Number
*
Your email address
*
Did you reside or stay at any of the following addresses (at any time from 4:00PM on 4 July 2020 until 11:59PM on 9 July 2020, and/or at 33 Alfred Street, North Melbourne at any time from 11.59PM on 9 July 2020 until 11:59PM on 18 July 2020, (together being the Relevant Period)? )
*
12 Holland Court, Flemington 3031
120 Racecourse Road, Flemington 3031
126 Racecourse Road, Flemington 3031
130 Racecourse Road, Flemington 3031
9 Pampas Street, North Melbourne 3051
12 Sutton Street, North Melbourne 3051
33 Alfred Street, North Melbourne 3051
76 Canning Street, North Melbourne 3051
159 Melrose Street, North Melbourne 3051
Unit number you resided or stayed in during the Relevant Period
*
*
During the Relevent Period, were you a resident of or visitor to the address you have nominated above?
Resident
Visitor
Do you consent to the Administrator reviewing the records formerly held by the Department of Health and Human Services (as it was known in July 2020) and now held by the Department of Health and/or the Department of Families, Fairness and Housing to check your eligibility to be a group member and verify your identity, age and address within the Estate Towers?
*
Do you consent to the Administrator reviewing the records formerly held by the Department of Health and Human Services (as it was known in July 2020) and now held by the Department of Health and/or the Department of Families, Fairness and Housing to check your eligibility to be a group member and verify your identity, age and address within the Estate Towers?
Yes
Do you consent to the Administrator reviewing the records formerly held by the Department of Health and Human Services (as it was known in July 2020) and now held by the Department of Health and/or the Department of Families, Fairness and Housing to check your eligibility to be a group member and verify your identity, age and address within the Estate Towers?
No
Are you the parent, guardian or personal representative of a person who was born before 4 July 2020 and is:
*
a. under 18 years of age on 27 June 2023; and/or
b. under a disability or can’t look after themselves;
and who resided or stayed at the Estate Towers at any time during the Relevant Period?
Are you the parent, guardian or personal representative of a person who was born before 4 July 2020 and is:
Yes
Are you the parent, guardian or personal representative of a person who was born before 4 July 2020 and is:
No