Personal accident claim form

Transcription

1 Persnal accident claim frm Guidance ntes: Please arrange t return the fully cmpleted frm either by: Pst: Ftball PA Claims Team, Wdgate & Clark Ltd, The Red Huse, King Street, West Malling, Kent ME19 6QT r ftballpaclaims@wdgate-clark.c.uk The claim handler will cntact the injured player directly with their unique claims reference number within 5 wrking days f receiving the claim frm. If an address is prvided they will use this methd t cmmunicate with the injured player whilst dealing with the claim. T ensure benefits are paid prmptly, claimants will be given the ptin n the claim frm t elect fr their payment t be made by BACS, s please ensure this sectin f the claim frm is cmpleted. We strngly recmmend the player/claimant keeps cpies f all paperwrk and crrespndence sent t Wdgate & Clark Hw we use yur data T prvide ur services, we need t cllect and use infrmatin abut individuals such as their name and cntact details, as well as special categries f persnal data (e.g. abut their health infrmatin) and infrmatin abut criminal cnvictins and ffences. The purpses fr which we use persnal data may include arranging insurance cver, handling claims, fr crime preventin. Mre infrmatin abut ur use f persnal data is prvided in the Marsh Privacy Ntice at uk/privacy-ntice.html r in hard cpy n request by ing r writing t Data Prtectin Officer, Marsh Ltd, Twer Place, Lndn EC3R 5BU r dataprtectin@marsh.cm. Prviding the services may invlve the disclsure f persnal data t third parties such as insurers, reinsurers, lss adjusters, premium finance prviders, sub-cntractrs, ur affiliates and t certain regulatry bdies wh may require yur infrmatin themselves fr the purpses described in the Marsh Privacy Ntice. Depending n the circumstances, the use f persnal data described in this ntice may invlve a transfer f data t cuntries utside the UK and the Eurpean Ecnmic Area that have less rbust data prtectin laws. Any such transfer will be dne with apprpriate safequards in place. Checklist Useful Checklist ntes: Yu fully cmplete every questin befre yur dctr cmpletes his statement The bank accunt details f the payee has been cmpleted n page 8 Yu have signed and dated the patient access declaratin n page 7 The club secretary r a club fficial has signed the claim frm n page 8 Yu have signed the claim frm n page 8 Yu have enclsed all requested infrmatin/dcumentatin Yur attending dctr fully cmpletes the statement n pages 5 & 6 Require assistance? If yu have any questins, please call Wdgate & Clark n In sme circumstances, we (and ther insurance market participants) may need t cllect and use special categries f persnal data (e.g. health infrmatin) and/r infrmatin relating t criminal cnvictins and ffences. Generally, we are able t d this because it is necessary fr the insurance activities that we undertake r fr fraud preventin purpses. Where yu are prviding us with infrmatin abut a persn ther than yurself, yu agree t ntify them f ur use f their persnal data and, if requested by us, btain their cnsent t ur use f any special categries f persnal data such as health infrmatin and infrmatin relating t criminal cnvictins and ffences (e.g. by requiring the individual t sign a cnsent frm). Arranged by Claims handlers Underwritten by 1

2 Ftball team insurance Persnal Accident Insurance claim frm Club details (This sectin is t be cmpleted by yu) Full name f club: Plicy number Cntact address Pstcde: Cntact name Cntact telephne Affiliated Cunty FA League Claimant details: Full name: Date f Birth: Gender: MALE FEMALE Address: Pstcde: Hme telephne: Wrk telephne Fr security reasns please prvide a passwrd which will be required t access yur claims infrmatin: Passwrd: Emplyment details: What is yur ccupatin? Please describe yur duties: Please state average grss and net salary ver previus 12 mnths frm the date f the incident (please enclse cpies f 13 weeks payslips prir t the event) r ver the previus 36 mnths frm the date f accident if self emplyed (please prvide evidence f incme by means f Inland Revenue Tax Assessment frms r audited accunts): Grss: Net: Name and address f emplyer address f emplyer 2

3 Ftball team insurance Persnal Accident Insurance claim frm Accident details: Please give exact date and time when injured: Time: Please state fully: Where the accident ccurred: Was it an rganised fixture r a friendly (if applicable)? Type f playing surface (if applicable) e.g. grass, 3G, 4G, Astrturf (ld style sand based) Perid f Match (if applicable) 0-15mins 15-30mins 30-45mins 45-60mins 60-75min 75-90mins 90+mins Playing psitin (if applicable) Galkeeper Defender Midfielder Frward Hw the accident ccured: The injuries sustained: Brken Bnes (please indicate): Ft Ankle Tibia Fibula Wrist Arm Cheekbne Jaw Other Dislcatin (please indicate): Knee Shulder Elbw Hip Snapped/Ruptured Achilles Tendn Snapped/Ruptured Cruciate Ligament (please indicate): Anterir Cruciate Ligament Psterir Cruciate Ligament Cncussin Other (please use the space prvided) Have yu previusly claimed under this r a similar plicy? Yes N If Yes please prvide details Please give the name, address and plicy number f any ther insurance plicy that may cver this injury 3

4 Ftball team insurance Persnal Accident Insurance claim frm Hspital Statement: (Only cmplete this sectin if yu are claiming a hspitalisatin benefit) Please nte This sectin must be fully cmpleted by hspital medical staff r recrds - any fee fr cmpletin f this sectin is the respnsibility f the claimant Type f hspital/ward: Name f Dctr r Cnsultant: Dates admitted and released: Admitted: Released: Was any perid spent in intensive care? Yes N If Yes please prvide the dates: Frm: T: Was the patient subsequently cnfined t their hme n medical grunds? Yes N If Yes please prvide the dates: Frm: T: If there is any additinal infrmatin that yu feel is relevant, please prvide: Yur signature Qualificatins: Psitin: Please use validatin stamp r cmplete in BLOCK CAPITALS Hspital name: Address: Pstcde: Telephne: Validatin Stamp: 4

5 Ftball team insurance Persnal Accident Insurance claim frm Dctrs Statement: Please nte This sectin must be fully cmpleted by attending dctr. Patients name (Mr, Mrs, Miss, Ms) Date f Birth: Height: Weight: Please give full details f injury: Final diagnses: When did the patient first receive medical attentin fr this cnditin? Has the patient ever suffered with this r any similar cnditin befre the present episde? Yes N If Yes, please give details including dates and cnsultatin: Are yu the patients usual Dctr? Yes N If N, please give name and address f usual dctr: (Cntinued verleaf) 5

6 Ftball team insurance Persnal Accident Insurance claim frm Dctrs Statement cntinued: On what date did incapacity cmmence?: Is the patient still incapacitated?: Yes N If Yes, when will patient be able t return t wrk? If N, when did incapacity cease? If there is any additinal infrmatin that yu feel is relevant, please prvide Yur signature: Qualificatins: Please use validatin stamp r cmplete in BLOCK CAPITALS Name: Address: Pstcde: Telephne: Validatin Stamp: 6

7 Ftball team insurance Persnal Accident Insurance claim frm Access t Medical Reprts Act 1988: Befre yur attending dctr can give a medical reprt n this claim frm which is a requirement f this claim, yu must give yur cnsent. Befre giving yur cnsent, yu shuld be aware f yur rights under the act which are summised as fllws: 1. Yu may withhld yur cnsent. 2. Yu may see the reprt befre it is sent t us within 21 days frm the date f this reprt. 3. Yu may ask t see the reprt fr up t 6 mnths after the reprt is cmpleted. 4. Yu may ask the dctr t amend any part f the reprt which yu cnsider t be incrrect r misleading. If the dctr des nt agree with yur request yu may attach yur cmments t the reprt. NB: The dctr may withhld all r part f the reprt frm yu if he cnsiders that yu may be physically r mentally harmed by it. Patient Declaratin Having been made aware f my statutry rights under the Access t Medical Reprts Act 1988 in cnnectin with my claim: 1. I hereby cnsent t Wdgate & Clark seeking medical infrmatin frm my dctr wh at any time has attended me cncerning cnditins which may affect my physical r mental health. 2. Please tick ne f the fllwing ptins belw: I DO wish t see the reprt befre it is sent t Wdgate & Clark I DO NOT wish t see the reprt befre it is sent t Wdgate & Clark 3. I authrise such dctr t disclse such infrmatin t Wdgate & Clark. 4. I agree a cpy f this cnsent shall have the validity f the riginal. Signed Date 7

8 Ftball team insurance Persnal Accident Insurance claim frm Payee Bank details: Imprtant When the claim has been apprved, yu may have the payment credited direct t yur bank accunt. This payment methd is bth speedier and safer than by cheque. If yu wuld like t take advantage f this arrangement, then please cmplete the fllwing; Name f yur Bank/Building Sciety: Address including pstcde: Pstcde: Bank Srt Cde Accunt Number Accunt Name: Data Prtectin: The infrmatin that yu and yur medical representative have prvided in the claim frm and Dctr s Statement is sensitive data as defined by the Data Prtectin Act Sensitive data includes any infrmatin abut yur physical and mental health. We require yur cnsent befre we can prcess this r any ther such sensitive data that yu may have already prvided us with r may d s in the future. In rder t administer yur claim, this infrmatin will be used by Wdgate & Clark and XL Catlin (insurers) It may be held n cmputer and r in manual files fr administratin, and risk assessment purpses. We may disclse yur persnal data and sensitive data t, and may request infrmatin frm ther insurance cmpanies fr underwriting, claims handling and fraud preventin purpses. By returning this frm, yu cnsent t ur prcessing yur sensitive persnal data fr the abve purpses. Yu als cnsent t ur transferring yur infrmatin t cuntries which d nt prvide the same level f data prtectin as the UK, if necessary fr the abve purpses. If we d make such a transfer we will, if apprpriate put a cntract in place t ensure yur infrmatin is prtected. Where yu have prvided infrmatin abut anther persn, yu cnfirm that they have appinted yu t act fr them, t cnsent t the prcessing f their persnal data, including sensitive data, t the transfer f their infrmatin abrad and t receive n their behalf any data prtectin ntices. Declaratin: I declare that all the infrmatin given is t the best f my knwledge and belief, full true and crrect. Claimant signature: Parent/Guardian signature: (if claimant is Under 18) Club fficial signature: Psitin in club: Thank yu fr cmpleting this frm: Please return the cmpleted claim frm tgether with any enclsures t: Wdgate & Clark Ltd, The Red Huse, King Street, West Malling, Kent ME19 6QT Arranged by Claims handlers Underwritten by 8