Income Protection Initial Claim Form

Transcription

1 Income Protection Initial Claim Form Important information Please fully complete this claim form (pages 1 to 11). If there is insufficient space to fully answer a question, please use page 9. Please also arrange for your doctor to complete the Treating Doctor s Report (pages 12 to 16). Scheme Name or Employer (Business) Name Policy Number/Member Number Member details Title Mr Mrs Miss Ms Other Middle name First name Family name Date of birth (DD/MM/YYYY) address (Please provide your so notices relating to your application can be sent to you) Home telephone Business telephone Mobile phone number Residential address (your residential address cannot be a PO Box) Unit number Street number Street name Suburb State Country Postal address Same as residential PO Box number Unit number Street number Street name Suburb State Country What is your height and weight? Height (cm) Weight (kg) Trustee NULIS Nominees (Australia) Limited ABN AFSL Fund MLC Super Fund ABN Insurer MLC Limited ABN AFSL The Trustee of the Fund is part of the National Australia Bank Limited (NAB) group of companies (NAB group). Your insurance is not a liability of, and is not guaranteed by, NAB. MLC Limited uses the MLC brand under licence. MLC Limited is part of the Nippon Life Insurance group and not a part of the NAB group of companies. Any references to we, us and our means MLC Limited and Trustee refers to NULIS Nominees (Australia) Limited. Income Protection Initial Claim Form 1 of 16

2 Disability details 1 Describe the exact nature of your medical condition/s. 2 When did the symptoms of your medical condition/s first appear? (DD/MM/YYYY) 3 When did you first consult a doctor for this medical condition/s? (DD/MM/YYYY) 4 When was your last day at work? (DD/MM/YYYY) 5 Did you stop work because of your medical condition? No Please advise why you stopped work: Please go to Question 6 6 Is your condition the result of an accident? No Please go to Question 8 How, where and when did the accident occur?: 7 Was the accident reported (eg to your employer, the police etc)? No Please go to Question 8 Please provide details: Income Protection Initial Claim Form 2 of 16

3 Disability details (continued) 8 Provide the name and address of your usual doctor and/or surgery and the date of your most recent consultation. Name of Doctor/Surgery and Speciality (please print) Doctor s Telephone Doctor s Facsimile Date last consulted (DD/MM/YYYY) 9 How long have you been attending this doctor and/or surgery? days months years 10 Please advise details of all healthcare providers (eg, doctors, physiotherapists etc), you have consulted and the date first and last consulted for your medical condition (please use page 6 if space is insufficient). Name of Doctor/Surgery and Speciality (please print) Doctor s Telephone Doctor s Facsimile Name of Doctor/Surgery and Speciality (please print) Doctor s Telephone Doctor s Facsimile 11 Which doctor and/or surgery would best know the complete history of your medical condition? Name of Doctor/Surgery and Speciality (please print) Doctor s Telephone Doctor s Facsimile Income Protection Initial Claim Form 3 of 16

4 Disability details (continued) 12 Were you admitted to hospital for this medical condition? No Please go to Question 13 Please provide details below: Name of Doctor/Surgery and Speciality (please print) Doctor s Telephone Doctor s Facsimile Reason for admission Admission date (DD/MM/YYYY): Discharge date (DD/MM/YYYY): 13 What treatment has been prescribed by your treating doctor/s? Type of treatment/medication Dosage/frequency Prescribed by 14 Have any tests been conducted or recommended? No Please go to Question 15 Please provide details below: Type of test/s Dates of test/s (DD/MM/YYYY): Test Results 15 Has any further treatment been recommended? No Please go to Question 16 Please advise type of treatment: Income Protection Initial Claim Form 4 of 16

5 Disability details (continued) 16 Have you ever had this or any similar/related medical condition/s? No Please go to Question 17 Please provide details below: Nature of condition/s Date of episode/s (DD/MM/YYYY): Period/s off work (DD/MM/YYYY) from from to to Nature of doctor consulted (please print) Doctor s Telephone Doctor s Facsimile 17 Do you have any other medical conditions for which you are receiving treatment? No Please go to Question 18 Please provide details below: Occupation and income details 18 What was your job title and who was your Employer at the time you ceased work? 19 Provide the name and address of your employer or business (if self-employed). Nature of employer (please print) Telephone Facsimile Income Protection Initial Claim Form 5 of 16

6 Occupation and income details (continued) 20 Describe your work duties in detail, including the type of duties and and percentage of time doing manual and/or non-manual work. Describe type of duties Percentage of Manual work Percentage of Non-Manual work % % 21 Which duties of your occupation are you not able to perform because of your disability? 22 Which duties of your occupation are you still able to perform despite your disability? 23 Prior to your disability, what were your usual hours and days of work in a week? Hours worked per week Usual days worked per week Hours worked per day From To am/pm am/pm 24 What was your annual income from your full time occupation for the past 12 months, before tax, and net of business expenses (if applicable)? Do not include investment income. Annual Income $ $ Net of business expenses 25 Do you have any other source of income (eg, sick leave, investment etc)? No Please go to Question 26 Type of income: Amount $ 26 Indicate below if you are self-employed or an employee? Self-employed Please go to Question 27 Employee Please go to Question 28 Income Protection Initial Claim Form 6 of 16

7 Occupation and income details (continued) Complete Question 27 ONLY if you are Self-Employed: 27 Have you worked in the business in any capacity since your disability began? No What has happened to the business in your absence? Please provide details below: Type of work Full time Part time Date started (DD/MM/YYYY): Date ceased (DD/MM/YYYY): Income earned $ Complete Question 28 (a to c) ONLY if you are an Employee: 28a Since your disability began have you worked for your employer in any capacity? No Please go to Question 28b Please provide details below: Duties performed Full time Part time Date started (DD/MM/YYYY): Date ceased (DD/MM/YYYY): Employer s (Business) name Income earned $ 28b Have you continued to receive any income (eg, sick leave, wages, etc) from your employer since your disability began? Type of work Income earned $ 28c Will you have a job to return to at the end of your disability? No Please advise why this is the case: Please go to Question 29 Income Protection Initial Claim Form 7 of 16

8 Occupation and income details (continued) 29 Are you making a claim, or have you ever made a claim for this condition under workers or accident compensation, third party insurance or with Centrelink, Department of Veterans Affairs, or any other insurance company or government department? No Please go to Question 30 Please provide details below: Insurer/Department name (please print) Claim type (eg. Workers Comp) Contact person Claim number Gross Weekly Benefit $ 30 Describe your current daily activities (please use page 6 if space is insufficient). 31 What daily activities are you unable to do because of your medical condition/s? 32 Please provide details of any sports/pastimes you have that you have been unable to continue because of your medical condition? Income Protection Initial Claim Form 8 of 16

9 Occupation and income details (continued) 33 Have you returned to work? No When do you expect to return to work? Full time (DD/MM/YYYY) Part time (DD/MM/YYYY) When did you return to work? Full time (DD/MM/YYYY) Part time (DD/MM/YYYY) 34 Provide any other comments which may assist with the assessment of your claim. Additional information: If you use this page to provide additional information, please note the page and question number to which the additional information refers. Page number Question number Additional information Income Protection Initial Claim Form 9 of 16

10 Disclosure to Client Representative To assist with the claims process you may want a family member or friend to receive information regarding your claim. I acknowledge that the information provided may include any information that MLC Limited (the Insurer) holds about me in respect of my claim including health, lifestyle, employment, financial, and insurance information. I authorise the people listed below to receive information on my behalf about my claim. They have been made aware and have consented to their personal details (name, date of birth and relationship to me) being given to the Insurer. I have also provided them with a copy of the brochure sent to me by the Insurer which details how the Insurer handles personal information and privacy. 1 Name Relationship to me Date of Birth (DD/MM/YYYY) 2 Name Relationship to me Date of Birth (DD/MM/YYYY) Income Protection Initial Claim Form 10 of 16

11 Declaration and authority 1 I declare that the answers on pages 1 to 11 are true and complete. I have not made any false or misleading statement and I have included all information relevant to the assessment of my claim. 2 If any answers to the questions are not in my handwriting I certify that I have checked them and they are correct. 3 I understand that if I do not give the information requested by MLC Limited or its representative that MLC Limited may not be able to assess, investigate or pay my claim. 4 I understand that MLC Limited will disclose, collect and use the information covered by this Declaration and Authority solely for the purpose of its administration of the policy, including this claim, and not for any other purpose. 4.1 I hereby authorise MLC Limited to disclose my personal information (which may include sensitive or health information) to the following parties. I further consent to these parties collecting information about me and releasing to MLC Limited their report, including any information they may hold about me as relates to MLC Limited s administration of the policy, including this claim to: Any physician, hospital or any other healthcare provider who has attended or examined me in order for them to supply MLC Limited with full particulars of my medical history including copies of all hospital or medical records, referral letters, reports and details of any clinical notes that have been made. Any claims assessor, investigator, medical professional, healthcare provider, insurance reference service, credit reference service, legal or accounting firm, auditor, employer, consultant or reinsurer for the purposes of producing a report concerning my claim. Any benefit provider such as other insurers or government departments (including workers compensation insurers, Centrelink or similar benefit providers) that provides benefits in the event of my sickness and/or injury. 4.2 I authorise MLC Limited to provide my Financial Adviser with copies of all correspondence (which may include personal and sensitive information) between MLC Limited and myself in respect of the claim. I also authorise my Financial Adviser to make inquiries regarding the progress of the claim for the purpose of providing me with ongoing service. 5 A photocopy of this authority is as valid as the original. Name of Member (PLEASE PRINT) Signature Date (DD/MM/YY) Please attach copies of any reports and/or test results relating to your current medical condition you may have in your possession. Return this form and any attachments to: Claims Department MLC Life Insurance PO Box 200 North Sydney NSW 2059 Income Protection Initial Claim Form 11 of 16

12 Income Protection Initial Claim Form Treating Doctor s Report Important information Any charge for completion of this form is the patient s responsibility. MLC Limited complies with Privacy Legislation. Scheme Name or Employer (Business) Name Policy Number/Member Number Patient s details Title Mr Mrs Miss Ms Other Middle name First name Family name Date of birth (DD/MM/YYYY) address (Please provide your so notices relating to your application can be sent to you) Home telephone Business telephone Mobile phone number 1 Patient s occupation 2 How long has the patient been attending you and/or your surgery? days months years 3 Are you the patient s usual medical attendant? No 4 When did you first see the patient for the current medical condition? (DD/MM/YYYY) 5 When did the patient s symptoms first appear or the injury occur? (DD/MM/YYYY) Trustee NULIS Nominees (Australia) Limited ABN AFSL Fund MLC Super Fund ABN Insurer MLC Limited ABN AFSL The Trustee of the Fund is part of the National Australia Bank Limited (NAB) group of companies (NAB group). Your insurance is not a liability of, and is not guaranteed by, NAB. MLC Limited uses the MLC brand under licence. MLC Limited is part of the Nippon Life Insurance group and not a part of the NAB group of companies. Any references to we, us and our means MLC Limited and Trustee refers to NULIS Nominees (Australia) Limited. Income Protection Initial Claim Form 12 of 16

13 Patient s details (continued) 6 What is the patient s diagnosis and date of diagnosis? Date of diagnosis: (DD/MM/YYYY) 7 What are the patient s current symptoms? 8 Provide the history of the patient s medical condition. Please include dates of all consultations for this condition, details of treatment and results of any tests or investigations undertaken. Please attach copies of any test results, if available. Date of consultation (DD/MM/YY): Consultation details and treatment: 9 Has the patient required hospital treatment? No Please go to Question 10 Please provide details. Name of hospital Name of Doctor and Speciality Reason for admission Admission date (DD/MM/YYYY) Discharge date (DD/MM/YYYY) Income Protection Initial Claim Form 13 of 16

14 Patient s details (continued) 10 Has the patient ever had the same or a similar condition before? No Please go to Question 11 Please provide details. 11 Have any other doctors been consulted for this condition(s), or have you referred the patient to any other doctors for a further opinion, treatment or investigation/s for this condition(s)? No Please go to Question 12 Please provide details below Name of Doctor/Surgery and Speciality (please print) Doctor s Telephone Doctor s Facsimile Field of expertise Referral date if applicable (DD/MM/YYYY) 12 In respect of the patient s medical condition, have you issued any certificates to any other insurance company, or for workers compensation, Dept of Veterans Affairs or Centrelink? No Please go to Question 13 To whom? 13 Has the patient been totally disabled (ie not able to work in current occupation and not working)? No Please go to Question 14 For what period? From (DD/MM/YYYY): To (DD/MM/YYYY): What work duties has the patient been unable to do? Income Protection Initial Claim Form 14 of 16

15 Patient s details (continued) 14 Has the patient been partially disabled (ie. able to work part time or in a reduced capacity in current occupation)? No Please go to Question 15 For what period? From (DD/MM/YYYY): To (DD/MM/YYYY): What work duties has the patient been unable to do? 15 Is the patient still disabled? No When did the patient return to work? Full time (DD/MM/YYYY): Part time (DD/MM/YYYY): When do you consider the patient will be fit to return to work? Full time (DD/MM/YYYY): Part time (DD/MM/YYYY): 16 Provide any other details and/or additional comments. Income Protection Initial Claim Form 15 of 16

16 Declaration and authority I hereby certify that I have personally attended the above patient and that all the information supplied by me on this form is true and complete. I acknowledge that: this information is provided for the primary purpose of the assessment and investigation of a claim under a policy with MLC Limited; MLC Limited may provide copies of this form to third parties, for example medical specialists or claims assessors from whom MLC Limited seeks an independent report or to any other person deemed necessary to assist in the assessment or investigation of this claim. Name (please print) Telephone number Facsimile number Qualifications Signature Date (DD/MM/YY) Please attach copies of any reports and/or test results relating to the patient s current medical condition you may have in your possession. Return this form and any attachments to: Claims Department MLC Life Insurance PO Box 200 North Sydney NSW 2059 A Income Protection Initial Claim Form 16 of 16