Term Life Insurance Notice of Claim

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1 How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Section A: Insured s/deceased s details Section B: Your details Section C: Family contact details Section D: Details about the insured s estate Section E Insured s particulars Section F: Insured s doctor contact details Section G: Medical authority form Section H: Your declaration Term Life Claim Documents Required A certified copy of the insured/deceased s birth certificate A certified copy of the insured/deceased s death certificate The original policy document that was issued to the insured/deceased on / / You must also provide copies of the following reports or documents if applicable to this claim: The insured/deceased s will Any autopsy report, police report or coroners report Probate or letters of administration which has been granted Health Insurance Commission (HIC) information authority Send the claim form and all supporting documents to: Insurance Without the above information we will be unable to process your claim. This could delay any payment to your account that you may be entitled to. If you are having any difficulties completing this claim form, please contact our Customer Service Centre on Page 1

2 Privacy notice and consent This Privacy Notice contains important information about the collection, use and disclosure of personal information by Hallmark Life Insurance Company Ltd. ( us ). By submitting this claim through us, you consent to us collecting, using and disclosing personal information about you in the ways set out below. We cannot process your claim without your personal information. Generally, we collect: information provided in the Application Form; information you provide in Claim Forms; sensitive information (in particular, health information) where it is necessary to assess claims, but only with your express consent; information from third parties (such as employers, government bodies, medical practitioners, other insurers) where it is unreasonable or impracticable to collect the information from you. Such circumstances may include where we seek to verify the details you provided in your Claim Form. Collection, use and disclosure of your personal information We collect, use and disclose personal information about you: to provide and manage products and services or other relationships and arrangements, including to process receipts, payments and invoices; to develop new products and services; to administer your insurance policy, perform administrative tasks and manage business operations; for planning, product development and research; for fraud, crime prevention and investigation of insurance risks or claims; to handle insurance claims; to deal with complaints; to comply with the following laws that may require or authorise us to obtain information about you: Privacy Act 1988 Corporations Act 2001 Insurance Contracts Act 1984 Life Insurance Act 1995 Autonomous Sanctions Act 2011 Australian Securities and Investments Commission Act 2001 We may also collect, use and disclose your personal information to tell you about products and services of GE companies and other offers from third parties that may be of interest to you. Persons to whom we may disclose your personal information We disclose your personal information as necessary to third parties for the purposes set out above. Those third parties may include other GE companies (both in Australia and overseas), contractors, agents, service providers, medical practitioners, delivery companies, mail houses, call centres, debt collection agencies, researchers, reinsurers, your employer, data analysts, government or regulatory bodies and professional advisers. We limit the use and disclosure of any personal information we give those parties to the specific purpose for which we give it. Safeguarding personal information We will take reasonable steps to protect personal information about you that they hold and transmit, from misuse, interference and loss and from unauthorised access, modification and disclosure. Disclosure of your personal information overseas In some circumstances, for the purposes set out in this Privacy Notice, your personal information may be transferred by us to organisations located overseas and which do not have an Australian link (for example, a disclosure to an overseas recipient may be necessary for operational reasons. We may also use service providers based overseas). Where such transfers occur, arrangements will be put in place to protect your personal information. Whilst it is not practicable to list every country in which such recipients are locate; it is likely that the countries to which your information may be disclosed include: the United Kingdom, United States of America, Hungary, Philippines, South Korea, New Zealand, India, Mexico and China. Access and Correction You may contact us to request access to your personal information, or if you believe that the information that we hold about you is incorrect in any way, by: Calling ; or Writing to at,. Our Privacy Policy is available at and contains further information about how you may access and seek the correction of the personal information we hold about you. Complaints We aim to review and resolve your enquiries as quickly and fairly as possible. We will keep you informed of our progress. We will do all we can to provide you with the most suitable response specific to your situation and ensure, where possible, that your complaint is resolved to your satisfaction. Our Privacy Policy also contains information as to how you can complain about a breach by us of the Privacy Act 1988 (Cth) and how we will deal with such a complaint. Third Parties If you provide us with personal information about any other individual, such as an nominated beneficiary or an authorised third party to make enquiries on your behalf in relation to your policy, you must first ensure that the person concerned: has seen this Privacy Notice and understood its contents; and has separately agreed to their personal information being collected, used and disclosed in accordance with this Privacy Notice. Direct marketing opt-out The consents given by you in relation to the use of your personal information for direct marketing apply to contacting you by all relevant means (for example, by letter, or phone) and apply for an indefinite period of time, unless you expressly withdraw those consents by notice to us. If you do not want to receive direct marketing information from us, you may call us on Communication If you provide us with an address, you consent to electronic communications being sent to you via that address, including notices and reminders. To protect your privacy, we recommend that any address you provide to us be your personal address rather than, for example, an address accessible by your work colleagues or family members. Page 2

3 Section A: Insured s/deceased s details? Who needs to fill this out? All questions need to be answered by you Full name of insured: Policy issued on: / / Policy number: Address of insured prior to their death Postcode: Insured s date of birth: / / Claim number: Section B: Your details First name/s: Last name: Address: Postcode: address: Your relationship to the Insured (please tick one of the following): Wife/husband Defacto Son/daughter Family friend (please explain further): Solicitor acting for: Executor of estate Administrator of estate power of attorney Other (please explain further): Brother/sister/other relative (please explain further): Section C: Family contact details We require the contact details of at least one member of the insured s family. If you (the person completing this form) are not a family member, please complete this section by providing the details of at least one family member. 1. Relationship to the insured (wife, husband, defacto, son, daughter, etc.): First name: Last name: Postcode: Page 3

4 Section D: Details about the insured s estate D1. Will (a) Did the insured leave a will? Yes No If Yes, please provide copy and go to section D2. If No, go to section D3. D2. Probate (a) Please give the following details of the person named in the will as the executor of the estate: Name: _ Address Postcode: Telephone number: Relationship to the insured (wife, husband, defacto, son, daughter, etc.): (b) Has probate been granted? Yes No If Yes, please provide a copy and go to section D4. (c) Has an application for probate been made? Yes No If Yes, go to section D4. (d) Will an application for probate be made? Yes No Go to section D4. D3. Letters of administration (a) Please give the following details of the administrator or intending administrator of the estate: Name: Postcode: Telephone number: Relationship to the insured: (wife, husband, defacto, son, daughter, etc.): (b) Have letters of administration been granted? Yes No If Yes, please provide a copy and go to section D4. (c) Has an application for letters of administration been made? Yes No Go to section D4. Page 4

5 Section D: Details about the insured s estate (continued) D4. Third party interests (a) So far as you are aware, was the insured an undischarged bankrupt when they died? Yes No If Yes, please give bankruptcy reference number and name and contact details of the trustee in bankruptcy (if known): (b) So far as you are aware, before the insured died did they give any interest in the policy to any third party? Yes No If Yes, please give name and contact details of the third party and state the nature of their interest (if known): D5. Public trustee (a) Is the Public Trustee (or equivalent) involved in administering the estate? Yes No (b) If Yes, please identify which State or Territory Public Trustee (or equivalent) and give their reference number (if known): Page 5

6 Section E: Insured s particulars Date of death: : / / Has the cause of death been ascertained? Yes No If No, please explain: If Yes, what was the insured s cause of death? Were there any other conditions that contributed to the death? After the insured s death: (a) Was an autopsy performed? Yes No If Yes, was a report issued? Yes No (b) Was there a police investigation? Yes No If Yes, was a report issued? Yes No (c) Was there a coronial inquest? Yes No If Yes, was a report issued? Yes No Please provide the contact details for the person who is preparing an autopsy report, a police report or a coroners report: 1. Name: Postcode: 2. Name: Page 6

7 Section F: Insured s doctor contact details Please provide the following details of the doctors, (both general practitioners and specialists) who treated the insured in the period from 5 years before the policy was issued until the insured s death. (The date when the policy was issued appears on page 1). Please also provide details of hospitals where the insured was treated in the same period. We may use this information to obtain a medical report from the doctors or hospitals you have listed. If there is not enough room for this information, please attach a separate sheet. 1. Name of doctor/hospital: Period of treatment from: : / / to: / / 2. Name of doctor/hospital: Period of treatment from: / / to: / / 3. Name of doctor/hospital: Period of treatment from: / / to: / / 4. Name of doctor/hospital: Period of treatment from: / / to: / / Page 7

8 Section G: Medical authority form Please note: This section may only be completed by the executor/administrator of the estate, or the next of kin (wife, husband, defacto, son, daughter, etc). If you are not a person in one of these categories, please arrange for this authority to be completed by someone who is. Failure to complete this section may delay our assessment of the claim. Release of medical history information I, hereby authorise (print your name in full) all medical practitioners, specialists and hospitals stated in Section F to furnish Hallmark Life Insurance Company Ltd. with all information it may request regarding the late Print name of insured in full and their medical history, for the period / / to: / / The insured s date of birth was: / / The insured s residential address was: Postcode: My relationship to the insured is (Executor of estate, administrator of estate, wife, husband, defacto, son, daughter, etc.): My postal address is (if different from above): Postcode: Sensitive Information I agree to Hallmark Life Insurance Company Ltd. collecting the Insured s sensitive information (particularly health information) for the purpose of considering this claim. I understand that further information regarding how the sensitive information is collected, used, disclosed or stored is contained at page 2 of this claim form and the GE Privacy Policy (www.gemoney.com.au/privacy). Signed: Date: / / A photocopy of this authority shall be considered as effective and valid as the original. Section H: Your declaration I declare that the information supplied by me on this form is in every respect true and correct and that I have not withheld any information likely to affect the acceptance of the claim. Name: Signed: Dated: / / Page 8

9 If you have a complaint We want you to be completely satisfied with your policy and our service. If you re not happy about something, please contact us first. We have an internal dispute resolution procedure, and you can quickly get that started by calling or by writing to at, Sydney, NSW We ll do our best to resolve your complaint quickly and fairly, and we ll keep you informed of the progress. If your complaint is not resolved in this way, you can contact the following independent and impartial body that provides a free external dispute resolution service: Financial Ombudsman Service Mail: GPO Box 3 Melbourne VIC 3001 Telephone: Fax: (03) or We also have a brochure Do you have a complaint relating to insurance? which has everything you need to know about these procedures. Please call us and we ll send you a copy. Glossary Administrator Executor Letters of administration Probate Will A person to whom the court has issued letters of administration. The person named in a will as being responsible for administering the deceased person s estate. (An estate is the property that a person leaves when they die). An authority granted by a court where a person has died without having left a valid will, which authorises the administrator to administer the deceased person s estate in accordance with the laws that specify how in those circumstances the estate is to be distributed. Letters of administration may also be granted where a will has been made but no executor is named in the will, or where the will names an executor but that person is not willing or able to act. A certificate granted by the court that the will of the deceased person has been proved as valid, and authorising the person named as the executor in the will to administer the deceased person s estate in accordance with the terms of the will. A document in which a person states what it to happen to their property after they die. Page 9

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