DISABILITY COVER CLAIM

Transcription

1 89 Bute Lane, Sandton PO Box , Sandton, 2146 Tel: Fax: POLICYHOLDER DETAILS: DISABILITY COVER CLAIM Title s Surname Full name/s Policy number I R ID number Contact number Date of birth Physical address Postal address Income tax number Code Income tax office Code 2. YOUR CHECKLIST: Section 1-6 to be completed by the claimant and section 7-8 to be completed by the employer. te: This form is only complete if the following has been attached: Sick leave records for the past year up to the current date. Certified copy of the claimant s ID (photo must be visible). Copies of the claimant s monthly payslip as at the last day he was actively on duty, as well as the monthly payslip for the month just prior to that. All payments are to be made into a bank account. We require proof of bank details: three consecutive bank statements (not older than 3 months). A job description for the claimant s current position or employment contract. Letter from employer confirming hours worked for the past 6 months. 3. CLAIMANT HISTORY: EDUCATION HISTORY Qualification Year completed Institution FedGroup Life Ltd (Reg /018003/06) FAIS Page 1 of 10

2 3. CLAIMANT HISTORY: (CONTINUED) EMPLOYMENT HISTORY Please provide us with a history spanning throughout your career, including your present occupation. Name and address of employer/s From Date To Occupation / job title Remuneration Reason for leaving On which date were you last actively able to perform the duties of your occupation before contracting your medical condition? What is/was your full time occupation? Please specify the percentage of time spent on: Please list your main duties: Administrative duties 1. Manual duties Supervisory duties Travel (car, truck etc) TOTAL MUST ADD UP TO What is your current employment status? Please tick box. Working full time Working part time On sick leave On unpaid leave Retrenched Dismissed What alternative occupations do you think you are capable of doing with your current employer or elsewhere? What jobs are you interested in doing, including jobs for which you may not have experience or training? What are your plans for the future? When did the doctor say you can go back to work? FedGroup Life Ltd (Reg /018003/06) FAIS Page 2 of 10

3 3. CLAIMANT HISTORY: (CONTINUED) Have you previously received any payout for a disability claim? If yes, please give the details below. MEDICAL HISTORY What difficulties do you currently experience in performing your job? When did you first notice you had difficulty doing your job? Did your difficulties with your job start after an accident? If yes, please list the date of the accident and details about the accident. Date of accident: Was the accident reported? If yes, please list the case number below. On what date did you first consult a doctor in connection with your difficulties? What is your current medical problem or disability? What treatment or medication are you currently taking? Indicate any difficulties with daily activities such as walking, going to the toilet, cooking or looking after yourself: FedGroup Life Ltd (Reg /018003/06) FAIS Page 3 of 10

4 3. CLAIMANT HISTORY: (CONTINUED) Please list in the table below, ALL doctors/clinics you have visited in the past two years: Name of doctor Contact details Date of first visit Date of last visit Reason for visit Have you ever been to hospital? If yes, please list the name of each hospital, the date you went there and the reason for your visit. Name of hospital Date of admission Reason for visit INCOME DETAILS Are you receiving or do you expect to receive any additional income/money during your disability? If yes, please provide the details below. Are you earning any other money or have any other job at present? If yes, please provide details below. 4. PAYMENT DETAILS: To ensure fast payment and for your protection, payment will only be made by electronic funds transfer. Payment will only be made to the policyholder or as instructed by the policyholder. payment to a third party will be allowed. Name of account holder Name of bank Account number Account type Branch name Branch number DECLARATION BY CLAIMANT: In my capacity as the claimant, I declare and warrant that all statements and answers which may now or at the time be given in connection with this claim, whether in my handwriting or not, to be true and complete. I further understand that any incorrect statements or nondisclosure, which materially affect the assessment of this claim, will entitle FedGroup Life to declare this claim null and void. It is my initial responsibility as the claimant to provide medical and other documentary evidence of disability at my own cost. It is my responsibility to prove that I am disabled in terms of the policy provisions. FedGroup Life Ltd (Reg /018003/06) FAIS Page 4 of 10

5 5. DECLARATION BY CLAIMANT: (CONTINUED) I authorise any person, possessing of any information relating to illness or injury of the claimant, to furnish FedGroup Life or its representatives with such information insofar as it may be necessary for FedGroup Life s consideration of this claim. I understand that representatives of FedGroup Life may be other health professionals, whom I have never consulted before in the past and I further give permission for such representatives to provide feedback to FedGroup Life on any consultation/medical examination I may have had or will have with them in the future. FedGroup Life is hereby authorised to make payment as instructed above and I acknowledge that payment by FedGroup Life of the benefits claimed shall release FedGroup Life from all liability in respect of such benefits. Claimant s signature Date 6. CONFIRMATION OF CLAIMANT DETAILS: EMPLOYMENT DETAILS Date claimant commenced service with you Date claimant joined the policy Date on which you became aware that the claimant might be disabled On which date was the claimant last actively able to perform all duties of his/her job? Did the claimant work in a full-time, permanent capacity for you on the last day at work? What was the average number of hours previously worked by the claimant in any one week, before illness/injury affected his/her performance? Date on which the claimant returned (if he/she has returned after disability) Hours Days absent from work in the last two years (Please attach sick leave records and medical certificates) From Dates To Number of working days absent Type of leave taken (annual, sick, unpaid, etc.) Reason FedGroup Life Ltd (Reg /018003/06) FAIS Page 5 of 10

6 7. CONFIRMATION OF CLAIMANT DETAILS: (TO BE COMPLETED BY THE EMPLOYER) From Dates To Number of working days absent Type of leave taken (annual, sick, unpaid, etc.) Reason Average gross monthly income earned during the year before the claimant s current condition (excluding overtime and any other non-pensionable allowances) R Did the claimant s pensionable income fluctuate during the year prior to the commencement of his/her condition? If yes, please supply details: Is the claimant currently on unpaid sick leave? If so, from what date? Gross monthly income before the condition R Gross monthly income since the start of the condition R Effective date Effective date Are you aware of any other source from which the claimant may potentially receive additional benefits, e.g. the Road Accident Fund and the Workman s Compensation Fund? If so, please complete the table below. Source of benefit Amount Lump sum / monthly benefit payments Date of finalisation of claim Have you submitted a disability benefit claim for this claimant before? If yes, please supply details: Please indicate the claimant s full employment history at his/her current employer, from the most recent to the earliest position: Most recent Previous Earliest Date started Job title Education qualifications required for that position Experience required for that position FedGroup Life Ltd (Reg /018003/06) FAIS Page 6 of 10

7 7. CONFIRMATION OF CLAIMANT DETAILS: (CONTINUED) Most recent Previous Earliest Broad description of duties performed Date leaving Salary at the date of leaving Please list the claimant s main duties for his current position and the percentage of time spent on each duty: The main duties of the claimant s current position Percentage of time spent on each duty TOTAL MUST ADD UP TO 100 Please specify the percentage of time spent on: Managerial/supervisory Light manual < / = 10kg Machine operator Admin/clerical Heavy manual > 10kg TOTAL MUST ADD UP TO 100 Travel What other jobs within your organisation is the claimant qualified to do? In reference to the question above, are there currently any vacancies for these positions? If yes, please provide the details below. CURRENT WORK ENVIRONMENT What percentage and hours per day does the claimant work? Percentage Hours Percentage Hours Indoors Outdoors At heights At depth Wet areas Dry areas FedGroup Life Ltd (Reg /018003/06) FAIS Page 7 of 10

8 7. CONFIRMATION OF CLAIMANT DETAILS: (CONTINUED) How often is the claimant exposed to the following conditions? Constant (67-100) Frequent (34-66) Occasional (6-35) Rare (1-5) Average hours per day Dust Vibration ise Fumes Heat Cold Other: What occupational health and safety measures do you currently have in the workplace, taking into account the working conditions you have outlined above. For example, do you have safety harnesses, dust masks, ventilators, ergonomic chairs, etc. in the work environment and when were they put in place? Temperature range in place of work Decibel range in place of work Type of dust and fumes Please give any details of any safety hazards in the claimant s job. Examples include slippery floors, furnaces, overhead cranes etc. Please list all items, equipment, tools, materials and machinery used in the claimant s current job: CURRENT PHYSICAL REQUIREMENTS What is the frequency and AVERAGE times spent on the following activities during a NORMAL working day, i.e. prior to injury/illness? Constant (67-100) Frequent (34-66) Occasional (6-35) Rare (1-5) Average hours per day Sitting Standing Walking on even/flat ground Walking on uneven ground, e.g. gravel/outdoors Kneeling Stooping/bending Crouching/squatting Climbing on scaffolding, ladders or structures Use of both hands for tasks such as lifting Use of hands for precision/delicate work, where the preferred hand is mostly used FedGroup Life Ltd (Reg /018003/06) FAIS Page 8 of 10

9 7. CONFIRMATION OF CLAIMANT DETAILS: (CONTINUED) Sight Hearing Physical strength or power Reaching above shoulder Reaching below shoulder Does the claimant s job involve any of the following? Lifting weights Pushing weights Carrying weights Pulling weights Only complete this section if driving is a component of the claimant s job: Licence codes required Constant (67-100) Frequent (34-66) Occasional (6-35) Rare (1-5) Average hours per day Average weight (kg) Item lifted Number of lifts per day Type of vehicles driven Average distance driven km per day km per week km per month Only complete this section if flying is a component of the claimant s job: Type of aircraft flown Average distance flown km per week Average number of hours flown hrs per week OTHER REQURIEMENTS Does the claimant s job require any of the following abilities? If yes, please give examples of activities that utilise these abilities in the table below: Job functions where this activity is utilised Mental artithmetic Using calculator/computer Memory Concentration Decision making Problem solving Planning Verbal communication Written communication Electronic communication Telephonic communication Communiction with clients Communiction with colleagues Reading Listening Conflict resolution FedGroup Life Ltd (Reg /018003/06) FAIS Page 9 of 10

10 7. CONFIRMATION OF CLAIMANT DETAILS: (CONTINUED) Is the claimant required to supervise staff members? If yes, how many? Is the claimant still performing his/her full-time job? If no, why not? What attempts if any, have been made to adapt the claimant s working environment or his current duties, to accommodate his medical condition and associated work difficulties? What efforts have been made to place the claimant in an alternative position/job to accommodate his medical condition and work difficulties? Will you be willing to consider the return to work of the claimant in the future? When do you expect the claimant to resume his/her occupation: On a part-time basis On a full-time basis In what position? 8. DECLARATION BY EMPLOYER: I declare that the answers and statements I have made are true and correct and I have not omitted or withheld any material fact from FedGroup Life. FedGroup Life is hereby authorised to make payment as instructed above and I acknowledge that payment of the benefits claimed shall release FedGroup Life from all liability in respect of such benefits. I hereby warrant I have been duly authorised by the employer to sign this form on the employer s behalf. Name Designation Employer s signature (duly authorised) 9. CONTACT DETAILS: On completion, please send this form to FedGroup Life Date PO Box Sandton 2146 Tel: Fax: disabilities@fedgroup.co.za FedGroup Life Ltd (Reg /018003/06) FAIS Page 10 of 10