ANZ INCOME PROTECTION INITIAL INCOME COVER CLAIM FORM

Transcription

1 ANZ INCOME PROTECTION INITIAL INCOME COVER CLAIM FORM May 2016 Customer Services Phone Website anz.com GPO Box 4028, Sydney NSW 2001 Please note There are information security risks associated with using to send information. Print in black or blue ink. Please attach a separate page if you require more space for an answer. Please ensure questions are answered in full where possible. Incomplete and unanswered questions may result in your claim being delayed and could result in this form being returned to you for completion. INSURED S PERSONAL DETAILS Policy number(s) Date of birth Height cm Weight kg First name(s) Last name Residential address Suburb/Town State Postcode Postal address Suburb/Town State Postcode Work phone Business phone Mobile phone MEDICAL DETAILS 1. What medical condition(s) are you currently suffering from? 2. If the medical condition(s) were caused by an accident/injury, please provide the date and how the accident/injury occurred? Details of accident/injury Date 3. If the medical condition(s) were caused by an illness, what were the first symptoms and when did you first notice them? Symptoms Date first noticed 4. How was the condition diagnosed? Please provide copies of all pathology and/or imaging reports to confirm the diagnosis. Page 1

2 5. Please provide the contact details of your usual Doctor s surgery/clinic and the date you first attended in relation to this accident/injury. Contact details Date first consulted 6. Have you ever consulted a medical practitioner outside of Australia in relation to any of the symptoms you are now experiencing? Yes No If yes, please provide: Contact details 7. Please provide the dates and contact details of all medical providers (including chiropractors, physiotherapist, rehabilitation providers, etc.) you have consulted since you first noticed the symptoms of your condition. Date Contact details (i.e. Name, Telephone, Address) D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y 8. Were you admitted to hospital for the condition? Yes No If yes, please provide: Name of hospital Date of admission Date of discharge Please note: A Copy of the Discharge Summary must be included. 9. What treatment have you received for the condition? 10. Is your current treatment providing any relief of symptoms? Yes No If no, have you discussed this with your Doctor or treatment provider? Yes No If so, what was the outcome/comments? 11. What future treatment is planned for your condition? Page 2

3 12. Does the severity of your condition vary? Yes No If yes, please provide details. 13. Have you ever suffered from similar symptoms or a similar condition at any time in the past? Yes No If yes, please provide details. Yes No What were the symptoms or condition that you suffered? Doctor consulted Date CURRENT DISABILITY 14. As a result of your medical condition, on what date: Did you cease work in your usual occupation Full time and/or Did you reduce your working hours Part time If you are working or worked part time please describe the duties performed and the number of hours you performed these per week. Duties performed Hours per week Dates From/ To e.g. Computer use 15 If the duties and hours have changed since the onset of the accident/injury or illness, please indicate how and when. Duties performed Hours per week Dates From/ To e.g. Computer use Have you returned to work? No When do you expect to return to work? Part time Full time Yes When did you return to work? Part time Full time If yes, please go to question 18. Page 3

4 16. Have you returned to any work, paid or unpaid? Yes No If yes, please confirm when space is required). and describe below eg Employer, Duties etc (please provide in notes section if more 17. Are you interested in assistance to return to work? Yes No USUAL OCCUPATIONAL DUTIES 18. What was your occupation(s) immediately prior to your disablement? 19. Please provide details of your usual occupational duties and approximate time spent completing these in an average day prior to your disablement. Duties Hours per day % Income derived Can undertake this duty now. Yes or No e.g. Computer use 10 50% Yes 20. How does your condition restrict/limit your ability to perform the duties listed in question 19? Please describe below. Duties Restrictions/Limitations 21. What is the average number of hours you worked per week in your usual occupational duties in the last 12 months? hours/week 22. How long have you been in this role? 23. Please advise whether any specific licences or qualifications are required to enable you to carry out your role? Yes No If yes, please provide details. Are they current? Yes No Page 4

5 Employees Please complete questions 24 to 27 then recommence at question 41. Self-Employed Please go to question 28. Please note if you are employed by your own business, you are considered to be self-employed. 24. If you are an employee, please provide details of your employer immediately prior to disablement. Company name Address Phone Fax/ Manager 25. Have you taken any sick leave since ceasing work? Yes No From: To: Gross amount $ (salary received) 26. What was your income for the last 12 months prior to disability? Gross salary $ Superannuation $ Any other benefits $ 27. Is your position or any other suitable position available for you to return to? Yes No If yes, please provide details. Go to question 41. SELF-EMPLOYED Please respond to these questions in detail. Please attach a separate page if you require more space for an answer. For example, please attach a separate page for each company, partnership or trust for which you are involved in generating an income. 28. Do you trade as: Sole trader Partnership Company Trust Company name Trading name ABN Address Phone Fax/ 29. If applicable, are you still a director of your company? Yes No If no, when did you cease being a director? 30. What was your involvement in the management of company affairs? 31. Did/do you give strategic direction? Yes No Please describe. Page 5

6 32. Did/do you lead/generate business? Yes No Please describe. 33. Did/do you do sales/quoting on work? Yes No Please describe. 34. Did/do you maintain the books and records for your company? Yes No Please describe. 35. How many full time and part time employees did/do you have and what was/is their job description? 36. How many casual/contract subcontractors, consultants, etc. did/do you have and what was/is their job description? 37. Are any family members involved in the business? Yes No If so, how many and what is their role? 38. Since ceasing work, has your business continued to operate? Yes No If yes, who is operating the business? Please provide details. 39. If yes, what involvement do you have in the continued running of the business? Page 6

7 40. Have you ever been made bankrupt or has any business which you have been associated with ever been placed in voluntary or involuntary liquidation or under administration? Yes No If yes, please provide details. 41. OTHER INCOME/BENEFITS 41a. Are you entitled to make a claim, or have you ever made a claim for this injury/illness from any of the following sources? Workers Compensation Yes No Motor Accident Compensation Yes No Other Disability Insurance Yes No Common Law Yes No Centrelink Yes No Other Yes No 41b. If yes to any of the above, please provide details in the below table Amount Dates from Dates to Ref. number Name and contact details of benefits provider 42. Please provide your bank details for payment of any benefit. BSB number Account name Account number Signature of Policy Owner Date D D M M 2 0 Y Y Page 7

8 Please turn the page to complete the form. OnePath Life will be unable to assess your claim if the form is incomplete. ADDITIONAL NOTES/COMMENTS AUTHORITY I hereby authorise any doctor, hospital, dentist, allied health professional or any other person whom I have consulted or who has attended me, to release to: OnePath Life; and/or its authorised representative; and/or all information with respect to any illness, accident or injury, medical consultation, prescriptions or treatment and copies of all hospital or medical records, reports or notes. I hereby authorise any employer, insurer or any other income provider, any accountant, lawyer or any other third party to release to OnePath Life any information or reports that it requires for the assessment of the claim. I agree that a photocopy or a scanned, electronic copy of this authorisation shall be as effective and valid as the original. I agree I disagree Signature of Life Insured Date D D M M 2 0 Y Y DECLARATION I hereby declare that the information contained in this statement is true, complete and correct in every detail. I acknowledge my responsibility for the completeness and accuracy of the information, whether the answers have been written, entered or provided by myself or by any person on my behalf. I understand and agree that if I make any false or fraudulent statements or fail to advise OnePath Life of any relevant information regarding my claim, OnePath Life may be unable to assess my claim and may proceed to cancel my claim and/or my cover. I understand that I can be prosecuted if I make any fraudulent statement. I acknowledge that I have been provided with a copy of ANZ s Privacy Policy which is also available at ANZ s website. OnePath values your privacy and information security. Please be aware that is not a secure method of communication and there are risks with using to send information. If you wish to your claim form to us, we encourage you to consider encrypting it. For more information please contact us. I agree I disagree Signature of Life Insured Date D D M M 2 0 Y Y A4273/0416 Page 8