Disability/Sickness Claim

Transcription

1 AXA Builing 6 Chiswick Park 566 Chiswick High Roa Lonon W4 5HR Step 1: Check Your Policy Documents Disability/Sickness Claim Important tes You must be 100% unable to work an be in active employment for at least 16 hours prior to becoming ill. You will not be covere for a sickness that began before the start ate of your policy. Depening on the cover you have taken you may nee to wait either 14/30 or 60 ays from the ate of your isability before any payment can be mae Your insurance policy inclues terms & conitions that must be met in orer for your cover to be vali. When taking out your insurance policy, you woul have been supplie with a ocument etailing what these conitions are. Please check your policy ocument for the specific conitions of your cover. Step 2: Fill in Your Claim Form You can now register an complete your claim online by visiting clp.partners.axa/uk/claimsuk Alternatively, if you prefer you can complete this claim form an sen it to us: Make sure all sections are complete in full we nee all of this information to assess your claim as quickly as possible Make sure you inclue all ocumentation require from the list below Make sure you sign & ate your claim form without your signature for consent we can NOT assess your claim Step 3: Collect Your Documentation To assess your claim you nee to sen the following ocuments along with this Claim Form; Your employer nees to complete the employer s statement section of this claim form to confirm your absence from work. If your employer oes not fill this section in, we will also accept a letter from your employer on company heae paper confirming your employment an number of hours worke per week, or copy of a payslip issue immeiately before your claim ate. Your Doctor nees to complete the octor s statement section of this claim form. If your octor oes not fill this section in we will also accept a full meical report. If your claim is relate to a back conition, please sen copies of any raiological evience you have ha to ate. Self Assessment Tax Declaration (If you were Self employe). SEE PAGE 5 OF THIS CLAIM FORM FOR EXAMPLES OF WHAT THESE DOCUMENTS MAY LOOK LIKE IMPORTANT NOTE: Please o take your time to collect all the ocuments you nee for your claim. By sening everything together with your fully complete claim form this will help us assess your claim as quickly as possible an prevent elays. Step 4: What Happens Next? Once we receive this fully complete claim form an fully ocumente evience, we will register your claim an assign a claim reference number, this number will be quote at the top of all corresponence, so please make a careful note of it for future reference. With the ocumentation provie by you, we will assess your claim against the terms & conitions of your insurance cover. This process usually takes 14 ays. At which point we will sen you a letter to confirm our ecision; 3 If payment can be mae, we will explain how much will be pai, by when & to whom, plus any further action you nee to take to continue to receive payment. 3 If we cannot pay your claim we will explain the reason why. 3 If you o not provie enough information an/or ocumentation for us to make a ecision, or we nee to investigate further/clarify the information we will phone or write to you explaining this an what is require. This will result to a elay in your claim The next page will show you where to sen your claim Financial Insurance Company Limite (part of AXA) (Company FCA & PRA ) an Financial Assurance Company Limite (part of AXA) (Company , FCA & PRA ) are both authorise by the Pruential Regulation Authority an regulate by the Financial Conuct Authority an the Pruential Regulation Authority. Financial Insurance Group Services Limite (part of AXA) (Company FCA ) is authorise an regulate by the Financial Conuct Authority. Each company is registere in Englan with its registere aress at Builing 6, Chiswick Park, 566 Chiswick High Roa, Lonon W4 5HR. CP08068 DIS NCF 05/16 1

2 Where to sen your claim & ocumentation Once you have complete this claim form in full & have all your ocumentation gathere you can sen us your claim through the following methos: You can make your claim an submit your ocuments online by visiting clp.partners.axa/uk/claimsuk By Post: AXA Builing 6 Chiswick Park 566 Chiswick High Roa Lonon W4 5HR By Fax: By clp.uk.info@partners.axa If you can, we suggest you keep a copy of your complete claim form an supporting ocuments that you sent us, as it may be helpful in the future Dealing with emotional situations whether it s isability, eath or job loss is ifficult. We will work with you to make the claims process as clear an easy as possible. All the information we ask you to complete & ocumentation we ask you to provie will allow us to process your claim as quickly as possible. Incomplete claim forms an/or ocumentation will result in your claim being elaye. Occasionally we may nee more information or clarification in which case we will contact you. IT IS IMPoRTANT THAT You CoNTINuE To MAkE PAYMENTS under YouR loan / CREDIT AgREEMENT WHIlST WE ARE ASSESSINg YouR ClAIM Your Declaration I eclare that I have become eligible to make a claim uner the terms of my policy an claim benefit accoringly. I certify that, to the best of my knowlege, the above information is true an correct. I unerstan that if any information provie by me is foun to be eliberately misleaing or incorrect, this claim may be rejecte an my policy may be treate as invali. In such circumstances, I also unerstan that I will have to repay any benefit that I have receive to ate an that legal action coul be taken against me. I authorise AXA to make any enquires an obtain any information they consier relevant from any octor(s), employer(s), ex-employer(s), Employment Service/Benefit Agency, HMRC or elsewhere. I unerstan that I must provie evience to AXA to prove my claim. I accept that it is my responsibility to isclose all information necessary to HMRC an to meet any tax liabilities that may arise on claim payments. I unerstan an give explicit consent that the sensitive health an other information I provie about myself will be use by AXA, its agents an associate companies, other insurers, regulators, inustry an public boies (incluing the police) an agencies to process this insurance an any other insurance, hanle claims an prevent frau. This may involve the transfer of such information to other countries (incluing those outsie of the EEA which have limite or no ata protection laws). AXA has taken steps to ensure that your information is hel securely. You have the right to access your personal ata hel by AXA. If you believe that your personal ata hel by AXA is inaccurate you have the right to ask for this to be rectifie. Name (Print) Signature X Date 2

3 Your - To be complete by you Title Mr Mrs Miss Ms Date of birth Last Name First Name Policy Number Aress Finance Provier National Ins : Postcoe Phone Have you ha a previous claim? Mobile Phone. There maybe circumstances where we nee to contact you in reference to your claim. We may use the option of writing to you by . Please enter your preferre aress if you are happy for us to contact you this way. Employment Statement: If you are Employe - To Be Complete By Your Employer If you are Self Employe To Be Complete By Your Accountant Claimants Occupation Person that represents the Employer Start ate of work Name Date of incapacity to work Position Date of return to work Signature of Hours Per week Date Has the claimant previously suffere from this illness/accient whilst in your employment? Company/ Accountants Stamp: If yes please provie etails & ate Authorisation of Consent Form Name Claimants Occupation Relationship Please note this person will nee to know your aress an ate of birth shoul they contact us on your behalf. 3

4 Doctor s Statement Any fee payable for completion of this form is the claimants responsibility Patients full name Date of Birth Please provie etails of sickness or accient If accient, please give the cause. If the patient has a psychiatric illness or nervous isorer, incluing stress an stress-relate conitions have they been referre to a consultant? Date referre Consultants name If your patient suffers from more than one sickness or injury, please list them putting the most serious first. First ate your patient consulte you for this conition. Is the patients sickness or injury ue to self-inflicte injury, chilbirth, pregnancy or miscarriage, alcohol or rug abuse, surgical proceures an meical treatment performe for cosmetic reasons, civil commotion, riot or war, psychological or any mental conition? If yes, please provie etails: First ate you certifie the patient unfit for work. When will the patient be fit to resume work? If you o not have an exact ate, base on your best jugement within how many weeks or months will the patient be fit to start work again? If the patient has a back conition, have they ha an X-ray? Date of X-ray If yes, please provie etails: months weeks If the patient has been amitte to hospital please tell us the following. Date amitte Date ischarge Has the patient been referre to or treate by a hospital for this conition? Name of hospital Please avise us whether your patient has suffere from this or a relate conition before? If yes please give etails below. I certify that this patient is/was uner meical attention an in my opinion is/was totally prevente from engaging in his/her normal occupation or profession uring the perio inicate. Doctors signature Doctors name Telephone number Doctors aress Aress of hospital Doctors stamp Consultants name 4

5 Examples of ocumentation you nee to sen: Example of acceptable pay slip: Example of Self Assessment Tax eclaration (If you were self employe): Access to Meical Reports Act 1988 Before we can apply for a meical report from your octor, we nee your consent. Before giving your consent you shoul know that you have certain rights uner Access to Meical Reports Act Your main rights are as follows: a) You o not have to agree to a meical report b) You can see the report before your octor sens it to us, or uring the 6 months after that. c) You can ask the octor to change any of the report if you think it is wrong or misleaing. If the octor oes not agree, you can write your comments on a sheet of paper an attach them to the report. You can also attach to the report a statement of your views on any part of it where you an the octor o not agree an which the octor is not prepare to change. If you ask your octor for a copy of the report, you might have to pay for it. The octor oes not have to show you parts of the report which: Might amage you or anyone else s physical or mental health; Woul give away the octor s intentions for treating you, or Woul tell you about someone who has given information about you. (This oes not apply if that person agrees to you knowing or is a health worker looking after you). The octor must tell you if he or she has not shown you part of the report. If the whole report is affecte, your octor must not sen it unless you agree. If you tell us you want to see the reports before your octor sens them to us, you octor must show them to you first unless you fail to arrange to see them within 21 ays Please tick one box: Please tick ( 3 ) to see meical reports before they are sent to the company I o not wish to see meical reports before they are sent to the company Full Name (block capitals) Aress Date of Birth 5