Statement of Claim Form 3B total

Amount of claim includes economic loss, non-economic loss and other damages.

Treatment and care amounts remain separate statutory-benefit review items.

Separate items

Interest and claim costs stay outside the damages breakdown.

Statutory-benefit items are shown for review and are not added into the Form 3B claim total.

[If you are making a liquidated claim (ie claiming a specific amount of money), include the following information:]

$

Economic loss damages

Other damages

Statutory benefits / separate review items

Amount of claim equals: economic losses + non-economic loss + other damages. Interest and costs are separate.

Interest $
Filing fees $
Service fees $
Solicitors fees $
TOTAL $
Result: 0.00
Item Total
Amount of claim0.00
Interest (manual)0.00
Filing fees0.00
Service fees0.00
Solicitors fees0.00
Statutory benefits / review items (not included in total)0.00
Total0.00
Damages breakdown included in amount of claim Total
Economic losses 0.00
Past loss of earnings 0.00
Past superannuation 0.00
Additional income tax (Fox v Wood) 0.00
Future economic loss 0.00
Future superannuation 0.00
Non-economic loss 0.00
Other damages 0.00
Statutory benefits / separate review items Total
Past treatment 0.00
Past gratuitous care 0.00
Future gratuitous care 0.00
Past paid care 0.00
Future paid care 0.00