Accident, Sickness & Critical Illness Claim Form

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1 Republic of Ireland Accident, Sickness & Critical Illness Claim Form Information Before you return your claim form, please ensure that you have me the required waiting period: Waiting period (after initial exclusion period) Accident & Sickness 30 Days Critical Illness 0 Days Please ensure that the claim form is fully completed. Section 1 by your Credit Union Section 2 by you Section 3a by your employer (if employed) Section 4b by you (if self-employed) Section 4 by your doctor Section 5 (the declaration) by you Please complete and return to: Assurant Services Ltd PO Box Park West Industrial Park Park West Road Dublin 12 Please review the checklist at the end of the claim form to ensure all relevant documentation is provided. 1. Loan Information To be completed by your Credit Union Credit Union Name What is the relationship between breadwinner and member? Credit Union Telephone Number Claimant s address Credit Union Account Number(s) Member s Name Are these loans protected by a breadwinner? If yes, what is the breadwinner s name: If there is a breadwinner, please submit the loan agreement confirming this. Date RPI first taken out Has member/breadwinner had continuous RPI on active loans since this date? Since taking out RPI, has any loan been Paid off in full? If so, when? For ALL active loans with RPI, please complete the table below. Loan Amount Draw down date Final payment date Repayment amount including interest APR Payment Frequency (eg. Weekly, fortnightly, every four weeks, monthly) Authorised Credit Union Official s name (BLOCK CAPITALS) Credit Union Stamp Authorised Credit Union Official s signature

2 2. Policyholder and Account Information To be completed by you Title (Mr, Mrs, Miss, Ms, other) Date last worked First Name Surname Date returned to work (if applicable) Please tick if you are: The Credit Union Policy Holder The Breadwinner Date of Birth Address If you are the breadwinner, please submit the loan agreement confirming this. Please advise if you are claiming for: An Accident Sickness Critical Illness When did your symptoms first appear/when you did have an accident? Home Telephone Number (including Area Code) Mobile Telephone Number Do you have any other interests, either financial or otherwise, in any other business venture of any kind? If so, please give full details. address Are you happy to receive communication from us, now or in the near future, by ? We will only discuss your claim where you have given permission for us to do so. Would you like to nominate another person to speak to us on your behalf, regarding your claim? If so, please write their names below. Please explain what is wrong/happened? (Please continue on a separate sheet or paper if necessary.) In the space below, please provide any further information that may assist in the assessment of your claim. (Please continue on a separate sheet or paper if necessary.) You are reminded that it is essential you provide all material information likely to influence the acceptance and assessment of this claim. If you have any doubts as to whether a fact is material, it should be disclosed.

3 3a. Employer s Certificate To be completed by your employer Employee s Name Employee s Job Title Type of employment: Full Time Part Time Temporary Contract Seasonal Other If Contract worker, please advise of: Number of times contract renewed Date contract is due to expire If Other, please give details Date returned to work (if applicable) Day resumed full activities (if applicable) If the employee has returned to work on reduced hours due to doctor's orders, please advise of: Number of reduced hours Resulting in the employee s monthly Gross wages being reduced by Employer s Name Employer s Address Average number of hours worked per week Date of hire Last date worked What is the employee s gross salary, including average overtime, commission, and/or bonus payments in the last 12 months prior to incapacity? What was/is the nature of employee s absence? Employer s Telephone Number (including area code) Your Name Your Position Are you related to the employee? If yes, give details. By signing the declaration below, you agree that the information provided is true and accurate to the best of your knowledge and belief. Signature Company stamp (if none is available, please provide a letter on Company letterhead paper, confirming that this form was completed by you.) Date 3b. Self Employment Certificate To be completed by you Company Name What is the nature of your business? Company Address Date that you last worked prior to your incapacity Have you returned to work? If so, on what date? Business Telephone Number (including Area Code) What duties could/can you still undertake while incapacitated? (Please continue on a separate sheet of paper if necessary.) Company Registration Number Date Self Employment Commenced Average hours per week worked prior to incapacity PLEASE PROVIDE YOUR SELF-ASSESSMENT TAX RETURNS FROM THE REVENUE COMMISSIONERS FOR THE PREVIOUS TAX YEAR, CONFIRMING YOUR ANNUAL INCOME

4 4. Doctor s Statement To be completed by your Doctor To be furnished without expense to the Insurance Company. The Insurance Company will not pay for any costs involved for requesting information that was asked for on this form, but not provided. PLEASE COMPLETE IN BLOCK CAPITALS. Patient s Name Patient s Date of Birth Please provide the date when the Patient was first registered at your practise? For each condition that the Patient is suffering from, please complete a line below. Diagnosis Date of 1 st symptoms What is the ICD-9 / ICD-10 code For the Patient s primary incapacity? Date 1 st seen by an medical practitioner Date certified unfit to work FROM Date certified unfit to work TO Please give full details and dates of all previous attendances for the above and associated complaints (continue on separate page if necessary) Please indicate if any of the following apply to the Patient s current condition: Cancer (malignant tumour including leukaemia, lymphoma and sarcoma) Coronary artery disease requiring by-pass surgery Heart attack Kidney failure requiring dialysis Stroke Major organ transplant (or on waiting list for such) Please advise what treatments and/or medication the Patient was, is or is due to receive. Please give dates. Was the Patient confined to hospital? If yes, please provide the date: From Has the Patient been certified fit to return to work? If so, on what dates? From To To If not certified to return to work, please indicate when the Patient will be. CONTINUES OVERLEAF

5 4. Doctor s Statement continued To be completed by your Doctor Is the Patient s illness or disability due to a self-inflicted injury, pregnancy or miscarriage, alcohol or drug abuse, surgical procedures or medical procedures performed for cosmetic reasons, or because of civil commotion, riot or war? If yes, please provide details below. Please advise if the Patient has been referred to a consultant who is registered with the Irish Medical Council or is a member of the Royal College of Psychiatrists and is recognised by the Irish Medical Council or the Royal College as being a consultant. If yes, please advise of the psychiatrist s name and address. For Patient s suffering from back-related conditions: Has the Patient has an MRI or X-Ray confirming a diagnosis? If yes, please provide a copy of this report and confirm date MRI/X-Ray was undertaken. By signing the below, you agree that the information provided is true and accurate to the best of your knowledge and belief. Signature Date Are you related to the Patient? If yes, please give details. Doctor s stamp

6 5. Declaration and Consent To be completed by you DATA PROTECTION ACTS 1988 & 2003 You have the right to access your personal data held by Assurant Solutions. However, the Data Protection Acts provide that medical information relating to an individual s physical or mental health should not be made available to the individual, in response to an access request, if it would be likely to cause serious harm to the physical or mental health of that individual. Such medical data can only be released to an individual after consultation with a medical practitioner. Further, if you believe that your personal data held by Assurant Solutions is inaccurate, you have the right to ask for this to be rectified. Information: During your claim, we may arrange for an agent to visit you. The purpose of such a visit will be to gather details regarding your claim in order to ensure an accurate assessment can be made. It is essential that you comply with such a visit; if you fail to comply, benefit may not be payable. Fraud: If a claim is fraudulent, or any false information is supplied in relation to any claim or policy application, all benefits under this policy will be forfeited, we will keep the premium you have paid and you may be liable to criminal prosecution. Privacy: Assurant Solutions is committed to maintaining the personal data that you provide in accordance with the requirements of data protection legislation. Our Privacy Statement, which is included in your policy document, provides further information about this and includes details of the Data Controller. The information you have supplied on this form and subsequent information and documentation provided in relation to this claim will be used in the administration of your claim. By signing this form, you are providing the required consent under the Data Protection Acts 1988 & 2003, for this information to be used for the processing and assessment of your claim. Declaration: By signing below, I declare the statements given in this claim form to be true and correct to the best of my knowledge and belief and I have not misrepresented or withheld any material fact. I agree that any benefits paid as a result of any knowingly incorrect statement shall be invalid. General Consent: By signing below, I authorise the Insurer, Administrator and all of their authorised representatives to verify all information and supporting documentation provided in relation to this claim. I consent to you or your Agents approaching my Former and/or Current Employers, Dept of Social Welfare Office and other appropriate sources for such information as you think necessary for the purposes of this claim and I agree that a copy of this document shall have the validity of the original. I consent to you sharing any information on this claim form and any other documentation or information relation to this claim, with other insurers and relevant third parties. Print your name Signature Date 6. Checklist To be completed by you To assist with the assessment of this claim and to reduce delays, please ensure that: The claim form is fully completed by all relevant parties. The claim form, signed and dated by you, is enclosed. (For Self Employed claimants) Your self-assessment tax returns from the Revenue Commissioners for the previous tax year confirming your annual income are enclosed. Assurant Solutions is a trading name in the UK and Republic of Ireland for the following companies which are all registered in England: Assurant Group Limited no , Assurant Services (UK) Limited no , Assurant General Insurance Limited no and Assurant Life Limited no Assurant General Insurance Limited and Assurant Life Limited are both authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Assurant Direct Limited no an appointed representative of Assurant Intermediary Limited no and Lifestyle Services Group Ltd no are both authorised and regulated by the Financial Conduct Authority. The UK branch of Assurant Services Limited is registered in England no FC The registered office of all the companies noted above is Assurant House, 6-12 Victoria Street, Windsor, Berkshire, SL4 1EN. Assurant Services Limited register no , Registered Office: 25/28 rth Wall Quay, International Financial Services Centre, Dublin 1, which is authorised and regulated in Ireland through The Central Bank of Ireland.

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