Personal accident claim form

Transcription

1 The issue of this claim form does not imply an admission of liability by us. Only a fully completed and signed claim form can receive our further assessment and consideration. Index Sections 1, 2, 9 and 10 must be completed by the Policyholder (or, if deceased, by the Policyholder s executor). Sections 3 to 8 need only be competed if the claim is for an event that applies to that section. Section 1 General Information Page 2 To be completed by the Policyholder (or, if deceased, by the Policyholder s executor). Section 2 Accident Report Page 2-3 Only to be completed by the Policyholder if accidental Injury occurs and will be claimed for in Section 3 - Temporary or Permanent Disablement. Section 3 Temporary or Permanent Disablement (accidental only) Page 3 To claim here the Policyholder must complete the Accident Report and Doctor must complete and sign the Medical Report. Additional documentation required: o Discharge forms from the hospital and relevant invoices; o Complete final report from an Orthopedic Surgeon and Occupational Therapist; o Letter from Employer, confirming termination of employment; o 3 X pay slips, including the pay slip for the month which includes the Date of Loss. Section 4 Accidental Death Page 4 To claim here this section must be completed by the Policyholder (or, if deceased, by the Policyholder s Executor). Additional documentation required: o Death certificate; o Police report; o Post mortem; o Executor s appointment. Section 5 Childbirth Page 4 To claim here this section must be completed by the Policyholder. Additional documentation required if you claim here: o Copy of Insured Person s (the person who gave birth) ID book; o Birth Certificate of newborn. Section 6 Retrenchment Page 5 To claim here this section must be completed by the Policyholder. Additional documentation required if you claim here: o Confirmation of the retrenchment from the Insured Person s Employer. Section 7 Dread Disease Page 5-6 To claim here this section must be completed and signed by a Doctor. Additional documentation required if you claim here: o Copy of policyholder s ID book; o Discharge forms from the hospital and relevant invoices; o Pathology report; o Medical History. Section 8 Hospitalisation (illness or accident) Page 6-7 To claim here the Medical report must be completed and signed by a Doctor. If Hospitalisation is due to accident, Policyholder must complete the Section 2 Accident Report Additional documentation required if you claim here: o Discharge forms from the hospital and relevant invoices; o Medical History. Section 9 Declaration Page 8 To be completed by the Policyholder (or, if deceased, by the Policyholder s executor). Section 10 Bank details Page 8 For a death claim please check the notes in Section 4 Accidental Death on which person s bank information is needed; For any other claim types this section is to be completed by the Policyholder; We also require a copy of the latest bank statement of the account. Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 1 of 8

2 Section 1 - General Information Policy Number: Policyholder s Name & Surname: Policyholder s ID no: Policyholder s contact information Address: Postal Address: Telephone: home work mobile Claimant s information (the person who the Policyholder is claiming for) Insured Person s Name & Surname: Insured Person s ID no: Section 2 Accident Report Policyholder to complete this section only for Accidental Injury if it is to be claimed for in:- Section 3 Temporary or Permanent Disablement. How did the accident happen? (full description) Date of Accident: Time of Accident: Place of Accident: Police Reference no: If it was a motor accident and the insured person was driving, was he/she tested for alcohol and / or drugs? Injuries suffered: Sick leave taken: When was employment terminated? to Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 2 of 8

3 Occupation and work description before accident (i.e. employer, position held, title, description of duties and dates from and to): Occupation and work description now (i.e. employer, position held, title, description of duties): Section 3 - Temporary or Permanent Disablement (following accidental injury only) Policyholder must complete the Accident Report in Section 2. Doctor to complete the following Medical Report. The Policyholder must obtain, at his or her own expense, the following report from a duly qualified and registered Medical Practitioner, who is not a member of the Policyholder s Family. 1. Full name of Patient: 2. Age: Height: Weight: 3. When you were first consulted about this injury? 4. Are you still in attendance? 5. If the Disability is due to the accident, when did this accident took place and what injuries were sustained? 6. Are you aware of anything in the Patient s previous medical history that may have contributed directly, or indirectly, to the occurrence of the accident, or which may be likely to retard recover? 7. Can you certify that the Patient is totally unable to follow his / her usual occupation or any other occupation by knowledge and / or training? 8. When did he / she first become unable to follow his / her usual occupation? 9. When did / can the Patient resume with his / her usual occupation? 10. Declaration: I hereby declare and warrant that the information given in this Medical Attendant s Report form is in every respect complete and true. Name: Qualification: Postal Address: Telephone no: Date: Signature / Stamp: Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 3 of 8

4 Section 4 - Accidental Death Full description of Accident (how did it happen): Date of Accident: Time of Accident: Place of Accident: Police Reference no: If it was a motor accident and the deceased person was driving, was he/she tested for alcohol and / or drugs? Post Mortem conducted? Police Report? Executor appointed? please provide details: Beneficiary s details on the policy (i.e. name, ID no. relationship): Please note: Bank details for accidental death claims o If it is death of the policyholder give Estate Late account details. o For death of insured family member not the Policyholder - give Policyholder account details. o If there is a Beneficiary nominated on the policy for the deceased person - give beneficiary account details (or if applicable a guardianship account nominated by his / her appointed legal representative. Section 5 - Childbirth 1. Full name of Patient: 2. Patient Date of Birth: 3. Place, Date, Time of birth: Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 4 of 8

5 Section 6 - Retrenchment 1. Name of employer at the time of retrenchment : 2. Date employed: 3. Date retrenched: 4. Reason for retrenchment: Section 7 - Dread Disease Doctor to complete this section. Medical Report: 1. Full name of Patient: 2. Age: Height: Weight: 3. Are you the Patient s usual Medical Attendant? 4. How many years has he/she been your patient? 5. When were you first consulted about this Illness? 6. When did the Patient first become aware of the symptoms? 7. When was medical advice sought? 8. Are you still in attendance? 9. Has the Patient been positively diagnosed with a Dread Disease? 10. If so, what is the official diagnosis of this medical condition? 11. Has this been the Patient s first diagnoses of this condition? 12. Has the Patient ever consulted for symptoms of this, or similar medical condition? If so, kindly provide us with the details: Date of Consultation Condition / Diagnoses Treatment 13. Please list below the nature of the medical conditions for which this Patient has consulted you over the past five (5) years (or since you have known him / her)? Date of Consultation Condition / Diagnoses Treatment Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 5 of 8

6 14. If the Patient was ever tested for HIV antibodies, please note the date and the test results: 15. If the Patient was diagnosed with Cancer, can this Tumor /s be histologically described as malignant, non malignant, pre-malignant, non invasive or as Cancer in situ? 16. If this Patient was diagnosed with Prostate Cancer, what is the Gleason score, and have this progressed to TNM classification T2MO? 17. Declaration: I hereby declare and warrant that the information given in this Medical Attendant s Report form is in every respect complete and true. Name: Qualification: Postal Address: Tel no: Date: Signature / Stamp: Section 8 - Hospitalisation If Hospitalisation is due to an accident, Policyholder must complete the accident report in section 2. If Hospitalisation is due to an Illness, Policyholder must complete section 1. Doctor to complete medical report below: Medical Report 1. Full name of Patient: 2. Age: Height: Weight: 3. Are you the Patient s usual Medical Attendant? 4. How many years has he / she been your patient? 5. When did the Patient first become aware of the symptoms and when were you first consulted about this illness? 6. When was medical advice sought? 7. Please give details of the condition or conditions that caused the patient to be in hospital? Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 6 of 8

7 8. Are you aware of any pre existing medical or physical condition of the patient that may have been one of the causes of him/her being in hospital or that may have lengthened his/her stay in hospital? If so, please provide us with the details i.e. what the pre-existing medical- or physical condition(s) were and when was the first diagnoses? 9. Was this the sole reason for requiring hospitalization? 10. Has the Patient ever been diagnosed and / or hospitalized for the same or similar condition? 11. If so, kindly provide us with the details: Date of Consultation Condition / Diagnoses Treatment 12. Please list below the nature of the medical conditions for which this Patient has consulted you over the past five (5) years (or since you have known him / her)? Date of Consultation Condition / Diagnoses Treatment 13. If the Patient was ever tested for HIV antibodies, or a Sexually Transmitted Disease, please note the date and the test results: 14. Declaration: I hereby declare and warrant that the information given in this Medical Report form is in every respect complete and true. Name: Qualification: Telephone no: Date: Signature / Stamp: Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 7 of 8

8 Section 9 - Declaration I hereby declare and warrant that the information given in this claim form is in every respect complete and true. I authorise any Medical Practitioner, Hospital or other person to provide Alexander Forbes Direct and / or their appointed Agents with any information they may require relating to the Medical History of the Patient. I agree that this consent shall remain in force at all times, and that a photo-copy of fax of this declaration shall be accepted as the original. Signed by the Policyholder, Claimant or Executor: Name & Surname: Date: Section 10 - Bank Details If it is claim for Accidental Death please check the notes in Section 4 before completing. For other claim types enter the policyholder s account detail. Name of Account Holder: ID no of Account Holder: Bank: Branch code: Type of Account: Account no: Please note: Alexander Forbes Insurance Company shall not be responsible for any financial loss suffered if payment is made in to an incorrect account because of incorrect details provided here. Issue: February 2012 Alexander Forbes Insurance Company Limited is an authorised financial services provider. Licence number Page 8 of 8