PERSONAL ACCIDENT BODILY INJURY

Transcription

1 CEGA Services Funtington Park, Cheesmans Lane, Funtington, Chichester, West Sussex, PO18 8UE phone: +44 (0) fax: +44 (0) PERSONAL ACCIDENT BODILY INJURY HOW TO SUBMIT A CLAIM 1. Please complete all sections of the attached claim form as fully as possible. 2. Please attach the following documents (as applicable): - Fully completed Treating Doctor/Consultant Statement (for all claims) - Copies of all police reports, newspaper articles, etc describing accident - Copy of admission/discharge form (Hospitalisation Benefit only) - For any Temporary Disablement claims, please provide wage slips for the 3 months prior to the accident, and medical certification covering any absence - For any Permanent Disablement claims, please provide wage slips for the 12 months prior to the accident - Accident Book entry - if the accident occurred on Employer s premises 3. Send the completed and signed claim form and all required documents to the above address 4. Retain a copy of all documentation for your records. Please note that you will be contacted by a Claims Examiner once these details have been received. Information Sheet

2 PERSONAL ACCIDENT BODILY INJURY CLAIMANT DETAILS Full Name Occupation Date of Birth Address of Permanent Residence Phone Number Relationship to Insured Company if not Employee EMPLOYER DETAILS Company Phone Fax Company Address Policy Number CLAIM DETAILS Date & Time of Accident Place where accident occurred Please describe the circumstance of accident (attach a separate sheet if required) Was the accident related to Injured Person s occupation If so, how Please describe the precise nature of the Injured Person s injuries Did police or other authorities investigate the accident? If yes please provide name, address & tel no. of Investigating Officer incl. crime reference no. How long has the Injured Person been absent from any employment as a result of the accident incl. date returned to work Has the Injured Person previously suffered from the above injury? If yes please state the date and details of this previous injury Please state Injured Person s basic salary inc. any overtime

3 CLAIM DETAILS (continued) Please list names and addresses of all treating doctor/consultants and hospital seen Date Name of Doctor or Consultant Details of hospital incl. telephone no. Please list names and addresses of any hospital/clinic attended in this case, together with the admission no. Hospital/Clinic Address Admission Date Discharge Date Admission No BENEFICIARY INFORMATION To whom should any payment be made? For Electronic Fund Transfer, please provide your full bank details; Bank Name, Bank Address, Account No, Sort Code, Swift Code (non-uk Banks) and Name of Account Holder. Please note if the Foreign Nationals" endorsement applies to this policy, payment will be made in accordance with the wording of that endorsement DECLARATIONS I declare that to the best of my knowledge, the particulars presented herein are true. I understand that any person who knowingly and with intent to defraud or deceive any insurance company, files a claim containing any materially false, incomplete or misleading information, may be subject to prosecution for insurance fraud. I also understand and consent that information herein may be made available to other insurers for underwriting and claims handling purposes and consent to Chubb Insurance Company of Europe SE and its authorized agents seeking information from other insurers to confirm any information presented. Signed Date Insured or Authorised Person Name Signed Date Line Manager or HR Department

4 TREATING DOCTOR S STATEMENT Date of accident Date of first medical treatment received Please describe in detail the nature of Injured Person s injuries Was the accident related to Injured Person s occupation? If so how? Did the Injured Person s bodily injury result solely from this accident and independently from any other cause? Or did the Injured Person have any injuries or illness prior to the accident that contributed to the accident or present condition. If yes, please describe Were any surgical procedures performed? If yes, please list all procedures with dates performed What are the Injured Person s current symptoms Will the Injured Person s injury lead to any permanent disability, in your opinion. If yes, please give full details Dates of total disability (from/to) Dates of partial disability (from/to) Date when claimant will able to return to work Is the Injured Person awaiting any specialist consultation and if so will any tests, treatment or procedures be carried our? If so please give details TREATING DOCTOR S INFORMATION Name, address and telephone no. of treating doctor Signed and official stamp of Treating Doctor (Compulsory)

5 ACCESS TO MEDICAL REPORTS ACT 1988 As part of your claim a medical report may be required from your doctor. However, before we can apply for a medical report your consent is needed. Before signing the consent to obtain a medical report at the foot of this form, you should know that you have the following rights. 1. You can withhold your consent, but if you should do so we may be unable to process your claim. 2. If you wish to see the report we will tell you at the same time that we write to the doctor and you will then have 21 days to contact the doctor about arrangements for you to see the report. Whether or not you wish to see the report before it is sent to us, the doctor must let you see a copy for up to six (6) months after it is supplied to us, if you ask for it. 3. You can ask your doctor to amend any part of the report, which you consider wrong or misleading. If the doctor will not agree to this, you may add your own comments. 4. Your doctor can, in certain circumstances, withhold from you the report or any part of it. Consent to Obtain Medical Report I have read the statutory rights above, under the Access to Medical Reports Act 1988 and I hereby agree to Chubb Insurance Company of Europe S.E. and its authorized agents seeking medical information from any doctor who at any time has attended me concerning anything which affects my physical or mental health in connection with this claim. I wish*/do not wish* to see the report before it is sent to Chubb Insurance Company of Europe S.E. and its authorized agents (*Delete as appropriate). Signed:... Date:... DECLARATION I declare that to the best of my knowledge the particulars given in this claims form are true. I understand that some of the information I have provided might be made available to other insurers for underwriting and claims handling purposes. I consent to Chubb Insurance Company of Europe S.E. and its authorized agents seeking information from other insurers to check the answers I have provided. I authorise that this information may be given to other insurers. Signature:... Date:...