CLAIM FORM SECTION A - INSURED PERSON S DETAILS. Details of Contact Person

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1 Third Party Administration CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM This form consists of several sections. Please provide answers to all of the information required in order to avoid delays with your claim. The issue of this form is not an admission of liability. SECTION A - INSURED PERSON S DETAILS Insured s Policy Number /s of the Insured Occupation/Business Industry/Trade Details of Contact Person Do you have any other insurance which will or could possibly cover this incident in whole or part YES NO If Yes, please advise in space provide: SECTION B THIRD PARTY S DETAILS 1 st Third Party Is this Party Legally Represented? YES NO If Yes, please state the firm and contact details if available: Fullerton Health Corporate Services (Aust) Pty Ltd GPO BOX 4276 Sydney NSW 2001 T: F: Australia E: claims@fullertonhealthcs.com.au Australia Singapore Indonesia Hong Kong Malaysia

2 Page 2 of 6 Please Explain how this party is involved: 2 nd Third Party Is this Party Legally Represented? YES NO If Yes, please state the firm and contact details if available: Please Explain how this party is involved: 3 rd Third Party Is this Party Legally Represented? YES NO If Yes, please state the firm and contact details if available: Please Explain how this party is involved: Date of Loss/Incident Date you were made aware of loss Place/Address of Loss/Incident SECTION C - DETAILS OF LOSS/INCIDENT Please provide full details of the loss explaining what and how the incident/loss occurred

3 Page 3 of 6 Were there any other parties at fault? YES NO If Yes, please advise the parties details AND how they were at fault: (If more than three parties involved, please detail on separate page & attach to form) 1 st Party How are they at fault? How are they at fault? 2 nd Party How are they at fault? 3 rd Party SECTION D BODILY INJURIES (IF NONE, SKIP TO SECTION E) Type of Injury sustained Approx. age of party injured Was the injured party treated? YES NO If Yes, please advise the treating parties details:

4 Page 4 of 6 Detail of Treatment provided Was Transportation used? YES NO If Yes, please advise the type of transport: Type Party s ATTACH ALL MEDICAL INFORMATION EVIDENCING THE INJURIES SUSTAINED Explain the type of property damaged SECTION E PROPERTY DAMAGE Explain the Nature of Damage Explain the Extent of Damage What is the approximate cost of the Damage caused $ Has the property been repaired? YES NO ATTACH ALL PROOF OF DAMAGE INCLUDING PHOTOS, SAMPLES, REPORTS, ETC. SECTION F DETAILS OF WITNESSES Witness 1 Phone Number: : Relationship to you: Witness 2 Phone Number: : Relationship to you: Witness 3 Phone Number: :

5 Page 5 of 6 Relationship to you: SECTION G OTHER INFORMATION If you have any other comments or other information about this incident/loss, please provided the details below. Please also advise if there is any fault on your behalf or whether you have admitted liability in any way. SECTION H STATUTORY AND/OR OTHER AUTHORITIES Has this incident/loss been reported to any statutory or supervising authority? YES NO If Yes, please provide details of the authority: Authority 1 Date Reported Reference Number Authority 2 Date Reported Reference Number Authority 3 Date Reported Reference Number SECTION I DOCUMENTATION Please circle & ensure all necessary and relevant documentation is attached a) Letter of demand YES NO N/A b) Correspondence from the third Party/ies YES NO N/A c) Details of the injured party s medical expenses YES NO N/A d) Quote/s for repairs YES NO N/A e) Witness Statements YES NO N/A f) Any hire/supply agreements and/or any other contractual arrangements YES NO N/A g) Any other relevant documentation YES NO N/A If Yes, please outline the relevant documentation provided

6 Page 6 of 6 SECTION I PRIVACY & DECLARATION Fullerton Health Corporate Services (FHCS) is committed to complying with the Privacy Amendment (Enhancing Privacy Protection) Act 2012 which amends the Privacy Act 1988 and has resulted in the introduction of the 13 Australian Privacy Principles (APPs). FHCS will ensure that all personal information held is treated in accordance with the Act and the APPs. All information collected is used only for the assessment of a claim or the provision of an insurance related service. In order to affect this, your personal information may be disclosed to or requested from third parties such as an insurer, broker, credit reference bureau, loss adjusters/assessors, other service providers or other parties as required by law. Consequently, given the placement of this insurance it may be necessary to disclose the information to a third party in the UK. If so, we will take reasonable steps to ensure that the overseas recipient of your information will not breach the APPs. FHCS will take all reasonable steps to ensure that the information held by FHCS is secure from any misuse, interference, loss, unauthorised access, modification or disclosure. FHCS has a privacy enquiries and complaints handling procedure to deal with any enquiry or complaint you may have about how we have collected, used or managed the information. If you would like to make an enquiry or complaint, please complete the Privacy Complaint or Query form that is available on our website at and send to privacy@fullertonhealthcs.com.au. Our complete Privacy Policy is located on the above website or can be obtained from us by contacting Privacy Authority and Declaration I understand that by investigating the claim or by accepting proof of the claim, FHCS has made no acceptance of liability, nor waived any of its rights in defence of any claim arising under the policy. I authorise any person or entity, including those referred to above, to provide to FHCS such information as FHCS in its absolute discretion considers relevant for its assessment of the claim or the entitlement to benefits. I will use my best endeavours and render all reasonable assistance and cooperation to FHCS in the assessment of the claim. I confirm that any information that I supply will be true and correct and that I will not withhold any information likely to affect the acceptance or handling of the claim. I declare that any answers in this form that are not in my own handwriting, they have been checked by me and I agree they are correct. I understand that if I do not consent to the terms of this authority or revoke my consent, FHCS may not be able to process or assess the claim. I appoint FHCS to do everything necessary or expedient to give effect to the transactions contemplated by the consents and authorisations in this document and to execute, on my behalf, any documents or to do such acts required to give effect to this Privacy Consent and Authority Declaration. Signature of Party of Party Date signed Signature of Witness of Witness Date Signed