Self Employed Disability (Accident or Sickness) Claim Form Section A Your details (To be completed by your) Title Surname Forename(s) Address Home Telephone Number Alternative Telephone Number Email Address Date of Birth Have you made any other insurance claims in respect of this Disability? Age If, please provide details to include policy number, name of company, address, contact telephone number and the type of policy you hold i.e, mortgage payment protection, loan protection etc. Please return all of the information noted in Section E along with your fully completed claim form for us to fully assess your claim. If you return your claim form without the required information we will not be able to provide you with a decision on your claim until this is received. Office Use Only Policy reference Please return this form by either email to: claims@paymentshield.co.uk Or by post to: Claims Team Paymentshield House PO BOX 229 Tel: 0345 6011 060 Fax: 0345 6011 080 Paymentshield and the Shield logo are registered trade mark of Paymentshield Limited. Paymentshield Limited, 2016. Authorised and regulated by the Financial Conduct Authority. Telephone calls to Paymentshield may be recorded for security purposes and monitored under our quality control procedures. Paymentshield Limited (registered number 02728936) is a company registered in England and Wales at Paymentshield House, Southport Business Park, Wight Moss Way, Southport, PR8 4HQ. Ref: Asset 00486 (06/16)
Section B Important Information & Declaration (to be completed by you) We aim to provide an efficient and understanding claims service, however, making false, misleading or exaggerated insurance claims is a crime. We participate in the insurance industry action to keep premiums down to ensure that the honest policy is not subsidising fraudulent claims. Declaration we are unable to start processing your claim without this signed declaration I am presently unable to work and wish to claim benefit under the Terms and Conditions of my policy. I declare that the answers I have given are true and complete to the best of my knowledge and belief. I understand that if I knowingly give false or misleading information, or my claim is exaggerated, I will have to repay any benefits I have received. I also understand that I will lose all rights under the policy and that legal action could be taken against me. I have been advised of my Statutory Rights under the Access to Medical Reports Act 1988 and have completed the authority to obtain a medical report/medical records. I understand that I must provide any evidence required by Paymentshield Limited Covéa Insurance and their representatives to prove my claim and must continue to do so during the period of any such claim. Insurers share information with each other to prevent fraudulent claims via a register of claims. A list of participants is available on request. The information you supply on this form, together with the information you have supplied on your application form and other information relating to the claim, will be provided to the register. I consent to the seeking of information from other insurers to check the answers I have provided, and I authorise the giving of such information. I authorise Paymentshield Limited, Covéa Insurance and their representatives to make any enquiries and obtain any information they consider relevant from my Employer, Mortgage Lender, Benefits Agency, Doctor, HM Revenue & Customs. A photocopy of this authorisation shall be considered as effective and valid as the original. DATA PROTECTION DECLARATION: I have read and understood the data protection information below. Signature Date Data Protection Information Sharing your personal information 1. We, Paymentshield, are the insurance administrator for your policy. Our company number is 2728936 registered office: Paymentshield, Paymentshield House, Southport Business Park, Wight Moss Way, Southport, PR8 4HQ. For the purposes of the Data Protection legislation we are the Data Controller. 2. Your personal data, including any sensitive personal data as determined under the Data Protection Act 1998, will be held by us on a database. For example your name, address, date of birth, marital status, family details, employment details, financial details and medical details. The database is an electronic computerised database held on our computers at our office. We may also hold your personal information in a paper based filing system. 3. Your information comprises of all the details we hold about you, your transactions, and includes information obtained from third parties. 4. We may use and share your information to help us: Deal with any claim you make on your insurance policy To detect and prevent fraud we may: Share information about you with other organisations and public bodies including the Police Undertake credit searches and additional fraud searches Check and/or file your details with fraud prevention agencies and databases and if you give us false or inaccurate information and we suspect fraud, we will record this. 6. Other than purposes outlined in paragraphs 4 and 5 above, we will not pass your information to any other person, firm, company or organisation. 7. Your information may also be used for research and statistical purposes and also crime prevention. This information may be transferred to other countries, including some outside the European Economic Area. In such instances any we will ensure it is kept secure and on the basis that anyone we pass it to provide an adequate level of protection. 8. We will keep your information for as long as you hold an insurance policy through us and for a reasonable period thereafter. 9. Access to your information: If you believe the information either we or the insurer hold about you is inaccurate, or you wish to receive a copy of the information we hold about you, please write to: The Data Protection Officer, Paymentshield Ltd, PO Box 229, Southport, PR8 9WU. Where copies of information are requested a fee of 10 will be charged, which must be paid before any information is sent. 5. We or your insurer underwriter may pass/share your information with third parties for the following purposes: To help us/the insurer to make decisions on your claim; If we have your consent; If we are permitted to do so by law; For the purposes of fraud prevention; If we transfer our agreement with you or any insurance policy we hold for you to a third party.
Section C Sharing information about your claim The details regarding your claim are considered to be private and cannot be disclosed to any other party without your express consent. This includes any other person named on the policy and any intermediary (e.g. financial advisor). If we are asked to do so, can we share information about your claim with the intermediary who introduced your policy to Paymentshield? If, please provide their full name and telephone number. Please note we cannot accept a company name. Name Telephone number If we are asked to do so, can we share information with any other person? If, please provide details of who we can share information with (we require this information for Data Protection when they call): Name Date of birth Relationship to you Name Date of birth Relationship to you Section D Your financial details (to be completed by you) Please note: we may request evidence of income for both insured parties (where appropriate) to support our assessment of your claim. This will allow us to determine the benefit amount applied to your particular claim. Your declared annual income for tax purposes for the last financial year Lender name and address Start date of your mortgage Current monthly mortgage repayment Current monthly life/endowment cover premium Current monthly buildings cover premium Current monthly contents cover premium Is your cover provided by this policy split with any other person? If, who is the cover split with? Annual income of second named person Please provide your Bank Account details where you would like any claims funds credited to. Bank name Bank Sort Code Account Number Branch Name of account holder Section E Important information needed with your claim. A copy of your mortgage statement dated within the 12 months prior to your claim. This must clearly show your name and address, your mortgage lender details and mortgage amount. A copy of a bank statement for the month prior to your claim and every other month since. These must show your mortgage payments and your name and address. (Please be advised, these will be requested every other month throughout the duration of any accepted claim) A copy of all sick notes provided to you confirming the periods you have been certified unfit to work. This will be required throughout your full claim period also. A copy of your latest Self Assessment Tax Calculations that you submitted to the HMRC. This must show the amount you have declared as Net Profit for tax purposes. Copies of correspondence, invoices and accounts from the time immediately prior to your claim date to show you were working at least 16 hours per week immediately before your claim.
Section F - Disability Details (to be completed by you) Nature of Accident/Sickness Date you last worked Have you returned to work? If yes, on what date? Is your disability as a result of an accident? If yes, give a brief description of the event Date first unable to work due to accident or sickness? If no, on what date do you expect to return Have you previously suffered from this or any related condition If yes, please provide all dates you have suffered from the condition and the duration Section G - Self Employed Details (to be completed by you) Trading Name & Address Business Telephone Number Date Trading Commenced Do you work a minimum of 16 hours per week every week? If, please provide a reason for this below: Has the business ceased trading? If, please give details of how the business remains trading: Are you in receipt of any remuneration from the business? Do you still participate in any way in the business? If, please give full details Your business accountant s name Accountant s address Accountant s telephone number Accountant s fax number
Additional Information
Section H - Doctor s statement (please arrange for your doctor to supply the following information) Please note - if a fee is payable to your Doctor for the completion of this section, you will be responsible for paying this. Patient s Full Name Address Date of Birth From what date do you hold all records for this patient? Nature of accident/sickness (please note the condition(s) not the procedure) If the patient suffers from more than one condition, please list in order of severity indicating which condition renders the patient unfit for work: a. b. Dates unfit from: Dates unfit from: Dates unfit to: Dates unfit to: Date of first consultation with any doctor in connection to the above condition(s) or any related condition(s). (If more than one condition, please confirm the dates for the main condition preventing the patient from attending work only) First date of firm diagnosis of symptoms in connection to the above condition(s). (If more than one condition, please confirm the dates for the main condition preventing the patient from attending work only) First date patient certified unfit for work (for the present absence from work) in connection to the above condition(s). (If more than one condition, please confirm the dates for the main condition preventing the patient from attending work only) Has the patient been admitted into hospital for the above condition(s)? If, please confirm dates of admission From To Is/are the condition(s) due to or related to a self-inflicted injury, medical complication of pregnancy and child birth, civil commotion or riot, or the consumption of alcohol, taking of drugs, other than under medical advice: If, please provide full details Is/are the condition(s) due to failure to follow any medical advice? If, please provide full details If the patient is suffering from a heart or chest related condition please can you confirm if they have even been treated for the following problems that could have contributed to the heart or chest condition: diabetes, smoking, drinking, obesity (or other overweight problems), high cholesterol or high blood pressure? If, please provide details of the problems contributing to the heart/chest condition and dates of consultations. Are you aware of any factors that could delay the patients recovery? If, please provide full details Has the patient been certified fit to resume his/her occupation? If, please provide the date of certification If, please confirm a prognosis for a return to work
I hereby certify this patient is/was receiving medical attention and is/was unfit to engage in their normal employment due to the condition(s) stated. Doctor s name Doctor s address DOCTOR S STAMP Doctor s telephone number Doctor s fax number Doctor s signature Date Please te: If you do not have an official stamp, please enclose a signed company compliment slip or letter head. There may be occasions where we need to contact you for further information. In this instance please confirm who the cheque should be made payable to Section I - Access to Medical Reports Act 1988 - Your rights under this Act - PLEASE READ Access to Medical Reports Act 1988 Under the Terms and Conditions of the policy, we may ask the doctor or consultant who is caring for you to fill in a medical report or provide your medical records so we can deal with your claim. To do this, we need your permission by signing the Access to Medical Reports Act 1988 (in rthern Ireland The Access to we can deal with your claim. To do this, we need your permission by signing the Access to Medical Reports Act 1988 (in rthern Ireland The Access to Personal Files and Medical Reports (rthern Ireland) Order 1991) declaration contained on the and Medical Reports (rthern Ireland) Order 1991) declaration contained on the proposal. Before doing so, you should read this section carefully, as it sets out your rights under the Access to Medical Reports Act 1988 (in rthern Ireland The Access to Personal Files and Medical Reports (rthern Ireland) Order 1991) in respect of the procedures for dealing with Personal Files and Medical Reports (rthern Ireland) Order 1991) in respect of the procedures for dealing with reports. You do not have to give your permission to Paymentshield Limited, Covéa insurance and their representatives to being given the report. However, under these circumstances, we may be unable to process your claim. If you give your permission, you have the right to tell your doctor (or consultant) that you wish to see the report before it is sent to us. In this case, your doctor (or consultant) cannot send it to us unless you have either seen the report or 21 days have passed without you contacting your doctor (or consultant) to arrange to view the report. If at first you decide that you do not want to see the report but change your mind before your doctor (or consultant) sends us the report, you can tell your doctor (or consultant). You will then have 21 days to see the report. We may not be able to go ahead with your claim without medical information. As a result, the sooner you act, the quicker we can consider your claim under this insurance. Whether or not you ask to see the report before it is sent to us, your doctor (or consultant), if you ask, must let you see a copy for up to six months after they send it to us. If you ask for a copy of the report, your doctor (or consultant) may charge a reasonable fee to cover the cost. If you see the report before it is sent to us, your doctor (or consultant) cannot send it to us until he or she has your permission. You can ask your doctor (or consultant) to change any part of the report and if they refuse, you can ask your doctor (or consultant) to send us a separate statement with the report giving the reasons why you consider it to be wrong or misleading. Your doctor (or consultant) can refuse to let you see any part of the report that in his or her opinion would be likely to cause you or others any physical or mental harm. They can refuse if any part of the report may reveal information about another person unless that person gives permission or has cared for you in a professional way. In these cases, your doctor (or consultant) must tell you. You would be limited to seeing any remaining part of the report. If it is the whole report which is affected, your doctor (or consultant) must not send it to us unless you give your permission. Access to Medical Reports Act 1988 Declaration I have read and understood the above section in respect of My Statutory Rights under the Access to Medical Reports Act 1988 (in rthern Ireland The Access to Personal Files and Medical Reports (rthern Ireland) Order 1991) in connection with my claim under this insurance policy. I consent to Paymentshield Limited, Covéa insurance and their representatives obtaining medical information from any Doctor who has attended me in respect of anything which affects my physical or mental health and I agree that a copy of this consent is valid as the original. I wish to see the reports before they are sent to the company I DO NOT wish to see the reports before they are sent to the company Signature Date Full Name in BLOCK CAPITALS