Do not complete this claim form unless you have been or will be off work for longer than your selected waiting period (30, 60 or 90 days)

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1 Income Protection Injury & Sickness Insurance Claim For further information contact Australian Income Protection Pty Ltd on: Phone: Do not complete this claim form unless you have been or will be off work for longer than your selected waiting period (30, 60 or 90 days) INSTRUCTIONS. 1. Section A is to be completed by you, the claimant. 2. Section B is to be completed by your treating doctor, if your claim is in anyway related to a psychological illness. We require a supporting medical report to be provided from your treating Psychiatrist/Psychologist. 3. Section C is to be completed by your employer. 4. Please enclose original medical certificates. 5. Mail to Australian Income Protection Pty Ltd PO Box R1196 Royal Exchange NSW 1225 IMPORTANT NOTICE Any fraud, misstatement or concealment by you in relation to any matter affecting this insurance in connection with making of any claim under it, will give us the rights provided for in the Insurance Contract Act, including where appropriate the right to reduce or refuse payment of any claim. SECTION A Claimant's Statement TO BE COMPLETED BY THE CLAIMANT All Claims will be paid via Electronic Funds Transfer, please provide the following information: Name on Account: Name of Financial Institution: BSB: Bank Account Number: All questions must be completed and claim form signed before claim will be processed. Ms/Mr/Mrs/Miss: Given Names: Surname: Suburb: State: Postcode: Date of Birth: Home Telephone: Mobile No: Weight: Height: ESI SUPER Membership Number: (Please call ESI SUPER on if you do not know your membership number.) Name of Employer: Address of Employer: State: Postcode: Work Telephone: Work Fax: Length of Employment: Occupation at time of disablement: Describe usual duties: Is your condition an Injury or Sickness (Please Circle) Are you self employed: Yes

2 Date of injury or onset of sickness: Time: If injured, how and where did it occur: Nature and extent of injuries or sickness: Have you ever had a similar condition in the past? Yes If yes give details: Date you first sought medical attention: Name and address of your medical Practitioner(s) for the past 5 years: You must fully complete your medical practitioner s information below or your claim may be delayed up to 10 weeks while we obtain a full Medicare history report. Name: Telephone: Fax: Date first consulted: Date last consulted: Yrs attended: Name: Telephone: Fax: Date first consulted: Date last consulted: Yrs attended: Name: Telephone: Fax: Date first consulted: Date last consulted: Yrs attended: If you have visited more than 3 medical practitioners over the last 5 years, please provide the information attached to this claim form. In respect of this injury or sickness are you receiving or planning to lodge a claim against: 1. Motor Accident Compensation Benefits Yes 2. Worker s Compensation Benefits Yes Insurance Co. 3. Employer Benefits (Sick leave, Holiday Pay, etc.) Yes 4. Centrelink and/or Government Disability Benefits Yes 5. Sports Insurance Yes 6. Other Insurance Policies Yes Insurance Co. Insurance Policy No. Contact Details. Type of Policy. If you answer Yes to any of the above please provide proof of claim / benefit. For example please provide acceptance letter, decline letter and copies of benefits paid.

3 Authority I hereby authorise any hospital, physician, employer, insurer, Health Insurance Commission or other person who have attended me to furnish to Australian Income Protection Pty Ltd or its representatives any and all information with respect to any sickness or injury, medical history, consultation, prescription or treatment and copies of all medical records. I also authorise any and all information regarding Worker s Compensation claims or claims with any other insurer to be released to Australian Income Protection Pty Ltd. I agree that a photo stat or fax copy of this authorisation shall be considered as effective and valid as the original. I also authorise Australian Income Protection to release any information requested by ESI Super or its representatives in relation to my claim. Declaration I do solemnly and sincerely declare that the foregoing particulars are true and correct in every detail and I agree that if I have made or in any further declaration in respect of the said claim make any false or fraudulent statements or suppress, conceal or falsely state any material fact whatsoever the Policy shall be void and all rights to recovery there under or in respect of past or future claims shall be forfeited. Signature of Claimant: Check List Name of Claimant: Date: 1. Have all sections been completed? Yes 2. Have you supplied a list of all treating doctors over the last 5 years? Yes 3. Is the doctor, who completed section B, your normal doctor? Yes 4. If no, has your normal doctor also completed a copy section B? Yes 5. Has your employer supplied a full 12-month wage report? Yes

4 SECTION B Doctor's Statement TO BE COMPLETED BY THE TREATING DOCTOR If this doctor is not your normal treating doctor you will need to have your normal treating doctor complete a copy of part B as well as your current treating doctor. Ms/Mr/Mrs/Miss: Patient s Name: State: Postcode: Age: Date of Birth: Occupation: Is your condition an Injury or Sickness (Please Circle) Date of injury or onset of sickness: Date on which you were first consulted: Date incapacity commenced: Are you the patient s usual doctor? Yes How long has the patient been attending you/your practice? Years Months What treatment is Claimant currently undergoing for his/her condition? Please list dates of all consultations in relation to the patient s condition: (If insufficient space please attach full list.) Has the Claimant been taking medication for his/her condition? Yes If yes, please state the medication and the date prescribed: (If insufficient space please attach a full list.) Please advise the date the claimant stated they were first aware of any symptoms in relation to their condition: Please provide your diagnosis: Please provide an outline of the symptoms the claimant is suffering from: In your opinion, what caused the current condition? History: In your opinion, is the injury or sickness work related? Yes Estimated date of return to work on Restricted Duties: Estimated date of return to work on Normal Duties: Has the Claimant been referred to a specialist for his/her problems, and if so, could you please supply the contact details?

5 Is the patient s current condition related to any previous injury? Yes Is the patient s current condition related to any previous sickness? Yes If so, did you treat the patient for the sickness/injury? Yes If yes, please give details of dates, treatment or advice for treatment given: (If insufficient space please attach a full list.) Have you, during your past care of the patient, advised them that their condition no longer requires any treatment or ongoing medical supervision, including the use of any prescribed medication? Yes If Yes, on what date was that advice given? What is your prognosis? I, Dr Of In the state of, being a registered medical practitioner, have examined the above named patient and certify the following to be a true description of his/her condition: And I further certify that the patient was totally disabled from following his/her usual duties From to (inclusive) Signed: Date: Qualifications: Telephone: State: Postcode: Facsimile:

6 SECTION C Employment TO BE COMPLETED BY THE EMPLOYER Employee Name: Employee Number: I hereby certify that the above employee has been unable to attend his/her usual occupation with the company as a result on an injury/sickness suffered whilst: He/she has been incapacitated since and is expected to resume duties on on A full weekly / fortnightly wage report is required for the 12 month period prior to the incapacity resulting in this claim. (This is required to calculate the benefit.) A full weekly / fortnightly 12 month wage report supplied: Yes He/She Salary Sacrifice wages within those 12 months: Yes Average per week gross: $ During the period of incapacity he/she received: $ Normal Pay from to $ Sick Pay from to $ Workers Compensation from to $ Other from to Please specify: Company Name: Postal Suburb: State: Postcode: Has been employed since: Was the employee employed: Full-time Part-time Casual Contractor To be terminated Employee s work status: Still an employee Terminated Workers Compensation Information (Please Note: This section must be completed even if the claim is not work related) Are you Self insured for Workers Compensation: Yes Name of current Workers Compensation Insurer: Policy Number: Resigned Is the employee on a current Workers Compensation claim: Yes If yes, does your company have an agreement to Top-Up the Workers Compensation benefits: Yes I hereby declare that this injury/sickness is/is not work related and is/is not covered by workers compensation (please strike out whichever is inapplicable) I hereby declare that we are prepared/ not prepared to take employees back on restricted/selected duties in the event of a non work related injury/illness. Signature of Manager: Name of Manager or paymaster (please print): Telephone: Date: Fax:

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