Group Total and Permanent Disablement (TPD) A. Disability Details. Scheme Name or Employer (Business) Name

Transcription

1 Group Total and Permanent Disablement (TPD) Claim Form MLC Limited ABN AFSL Please fully complete this claim form (pages 1 to 6). If there is insufficient space to fully answer a question, please use page 5. Scheme Name or Employer (Business) Name Policy Number/Member Number A. Disability Details 1 Describe the exact nature of your medical condition/s. Member Details Mr Mrs Miss Ms Other 2 If you had an injury, how did it occur? Surname (Family Name) (please print) Given Name(s) (please print) 3 When did the symptoms of your medical condition/s first appear? Date of Birth Country of birth Home address 4 When did you first consult a doctor for this medical condition/s? 5 Please provide 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 5 if space is insufficient). Doctor s name and address Postal address (if different to home address) Doctor s Telephone Reason seen Home telephone number Work number Mobile number Date first consulted Doctor s name and address Date last consulted What is your height and weight? height (cm) weight (kg) Doctor s Telephone Reason seen Group TPD Claim Form 1 of 6 Date first consulted Date last consulted

2 6 Have you required hospital treatment for this medical condition/s? No Go to Question 7 Provide details below B. Occupation and Income Details 8 What was your job title at the time you ceased work? Name of Hospital/Doctor and Speciality 9 When did you cease work? 10 Why did you cease work? Reason for admission 11 Describe your work duties in detail, including the type of duties and percentage of time doing manual and/or non-manual work. Describe type of duties Admission date Discharge date Name of Hospital/Doctor and Speciality Percentage of Manual work Percentage of Non-Manual work % % 12 Did you supervise other employees? Reason for admission Admission date Discharge date No Go to Question 13 How many: 13 Which duties does your medical condition prevent you from performing? 7 Have you ever had this or any similar/related medical condition/s before? No Go to Question 8 Provide details below Nature of condition/s 14 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 Date of episode/s Period/s off work from to Hours worked per day From am/pm To am/pm from Name of doctor consulted to 15 Were your usual hours and/or days of work modified in any way during your employment? No Go to Question 16 Reason/s for modification How modified When modified (day) (month) (year) Group TPD Claim Form 2 of 6

3 16 What level of education do you have (eg. Primary, Secondary or Tertiary)? 17 What qualifications or certificates do you have? 19 Since stopping your usual work have you worked in any other capacity? No Go to Question 20 Provide details below Type of work 18 Please list all previous jobs you have held (please use page 5 if space is insufficient). Full time Part time Date started Date ceased Income earned Work duties 20 Have you applied for any jobs since stopping work? No Go to Question 21 Provide details below Date started Date ceased Date of application Were you offered the position? No If no, please provide reasons for not being offered the position Work duties Date started Date ceased Date of application Were you offered the position? No If no, please provide reasons for not being offered the position 21 Are you attending any rehabilitation programmes or have you commenced any studies to help you return to the workforce? No Go to Question 22 Please provide details: Group TPD Claim Form 3 of 6

4 C. Other 24 Describe your current daily activities. 22 Are you making a claim, or have you ever made a claim for this condition under workers or accident compensation, third party insurance, Centrelink, Department of Veterans Affairs, or any other insurance company or government department? No Go to Question 23 Provide details below Insurer/Department name 25 What daily activities are you unable to do because of your medical condition/s? Claim type (eg Workers Comp) 26 Provide details of any sports/pastimes that you have been unable to continue because of your medical condition? Contact person Claim number Gross Weekly Benefit $ 27 Provide any other comments which may assist with the assessment of your claim. Insurer/Department name Claim type (eg Workers Comp) Contact person Claim number Gross Weekly Benefit $ 23 Do you have any other source of income (eg. sick leave, Investment etc)? No Go to Question 24 Type of income Amount Group TPD Claim Form 4 of 6

5 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 Group TPD Claim Form 5 of 6

6 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 (MLC) 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 MLC. I have also provided them with a copy of the brochure sent to me by MLC which details how MLC handles personal information and privacy. 1. Name Relationship to me Date of Birth 2. Name Relationship to me Date of Birth Declaration and Authority 1. I declare that the answers on pages 1 to 6 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 or its representative that MLC may not be able to assess, investigate or pay my claim. 4. I understand that MLC 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 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 their report, including any information they may hold about me as relates to MLC s administration of the policy, including this claim. Any physician, hospital or any other healthcare provider who has attended or examined me in order for them to supply MLC 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 to provide my Financial Adviser with copies of all correspondence (which may include personal and sensitive information) between MLC 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 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 Limited PO Box 200, North Sydney NSW MLC 12/05 Group TPD Claim Form 6 of 6