Income Protection Continuing Claim Form

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1 MLC Insurance Income Protection Continuing Claim Form MLC Nominees Pty Limited ABN AFSL RSE L The Universal Super Scheme ABN R Superannuation Fund Number ABN AFSL Please fully complete this claim form (pages 1 to 5). If there is insufficient space to fully answer a question, please use page 4. Please also arrange for your doctor to complete the Treating Doctor s Report (pages 6 & 7). Scheme Name or Employer (Business) Name Policy Number/Member Number A. Disability Details 1 Provide details of the exact nature of your medical condition? member Details Mr Mrs Ms Miss Other Surname (Family Name) (please print) 2 Provide details of your current symptoms and how these are preventing you from returning to full time work. Given Name(s) (please print) Date of Birth Home address 3 What treatment are you currently receiving for your disability? Postal address (if different to home address) 4 What further treatment has been recommended or planned? Home telephone number Work number ( ) ( ) Mobile number Page 1 of 7 Income Protection Continuing Claim Form

2 5 Provide details of all healthcare providers (eg doctors, physiotherapists, etc) you have consulted in relation to your current disability, including their field of expertise, since your last claim form. Name of Doctor/Surgery and Speciality B. Other 7 Are you making a claim, or have you ever made a claim for this condition under workers or accident compensation, third party insurance or with Centrelink, Department of Veterans Affairs, or any other insurance company or government department? No Go to question 8 Provide details below Insurer/Department name Telephone Number ( ) Reason seen Dates seen Claim type (eg Workers Comp) Name of Doctor/Surgery and Speciality Contact person Claim number ( ) Gross Weekly Benefit $ Telephone Number ( ) Reason seen Dates seen 6 Provide details of any hospital treatment you have undergone since you completed your last claim form. Name of Doctor/Surgery and Speciality 8 Do you have any other source of income (eg sick leave, investment etc)? No Go to question 9 Type of income Amount $ 9 Are you still unable to work? No When did you return to work? Full time Part time When do you expect to return to work? Full time Part time Telephone Number ( ) Reason seen Admission date Discharge date Page 2 of 7 Income Protection Continuing Claim Form

3 10 If you have not yet returned to work, do you have a return to work plan, or have you discussed a return to work plan with your doctor? No Please advise the reason for this situation: Give details of your return to work plan 11 Which of your normal duties are you unable to perform due to your disability? 12 Which of your normal duties are you able to perform? 13 Provide any other comments which may assist with the assessment of your claim. Page 3 of 7 Income Protection Continuing Claim Form

4 ADDITIONAL INFORMATION: If you use this page to provide additional information, please note the page and question number to which the additional information refers. Page Number Question Number Additional Information Page 4 of 7 Income Protection Continuing Claim Form

5 Disclosure to Client Representative To assist with the claims process you may want a family member or friend to receive information regarding your claim. I acknowledge that the information provided may include any information that (MLC) holds about me in respect of my claim including health, lifestyle, employment, financial, and insurance information. I authorise the people listed below to receive information on my behalf about my claim. They have been made aware and have consented to their personal details (name, date of birth and relationship to me) being given to MLC. I have also provided them with a copy of the brochure sent to me by MLC which details how MLC handles personal information and privacy. 1 Name Relationship to me Date of Birth 2 Name Relationship to me Date of Birth Declaration and Authority 1 I declare that the answers on pages 1 to 5 are true and complete. I have not made any false or misleading statement and I have included all information relevant to the assessment of my claim. 2 If any answers to the questions are not in my handwriting I certify that I have checked them and they are correct. 3 I understand that if I do not give the information requested by MLC or its representative that MLC may not be able to assess, investigate or pay my claim. 4 I understand that MLC will disclose, collect and use the information covered by this Declaration and Authority solely for the purpose of its administration of the policy, including this claim, and not for any other purpose. 4.1 I hereby authorise MLC to disclose my personal information (which may include sensitive or health information) to the following parties. I further consent to these parties collecting information about me and releasing to MLC their report, including any information they may hold about me as relates to MLC s administration of the policy, including this claim to: Any physician, hospital or any other healthcare provider who has attended or examined me in order for them to supply MLC with full particulars of my medical history including copies of all hospital or medical records, referral letters, reports and details of any clinical notes that have been made. Any claims assessor, investigator, medical professional, healthcare provider, insurance reference service, credit reference service, legal or accounting firm, auditor, employer, consultant or reinsurer for the purposes of producing a report concerning my claim. Any benefit provider such as other insurers or government departments (including workers compensation insurers, Centrelink or similar benefit providers) that provides benefits in the event of my sickness and/or injury. 4.2 I authorise MLC to provide my Financial Adviser with copies of all correspondence (which may include personal and sensitive information) between MLC and myself in respect of the claim. I also authorise my Financial Adviser to make inquiries regarding the progress of the claim for the purpose of providing me with ongoing service. 5 A photocopy of this authority is as valid as the original. Name of Member (please print) Signature Date Please attach copies of any medical certificates or test results relating to your medical condition you may have in your possession. Return this form and any attachments to: Claims Department PO Box 200, North Sydney NSW 2059 Page 5 of 7 Income Protection Continuing Claim Form

6 MLC Insurance Income Protection Continuing Claim Form Treating Doctor s Report MLC Nominees Pty Limited ABN AFSL RSE L The Universal Super Scheme ABN R Superannuation Fund Number Any charge for completion of this form is the patient s responsibility. MLC complies with Privacy Legislation. ABN AFSL Scheme Name or Employer (Business) Name 4 What treatment is the patient currently receiving and how is the patient responding to this treatment? Policy Number/Member Number patient s Details Mr Mrs Ms Miss Other 5 What further treatment is planned or recommended? Surname (Family Name) (please print) Given Name(s) (please print) 6 How often are you seeing the patient (eg weekly, monthly etc )? Date of Birth 1 What is the patient s current diagnosis? 7 Have any other doctors been consulted for this condition(s), or have you referred the patient to any other doctors for a further opinion, treatment or investigation/s for this condition(s) since the last treating Doctor s Report was completed? No Go to question 8 Provide details below Name of Doctor and Speciality 2 Provide details of any new developments in the patient s condition since the last treating doctor s report was completed. 3 What are the patient s current symptoms? Field of expertise Referral date if applicable 8 Provide the date of your most recent consultation with the patient (not including the date you completed this form) 9 When is your next appointment with the patient? Page 6 of 7 Income Protection Continuing Claim Form

7 10 To the best of your knowledge, is the patient now: (please tick the appropriate box) (a) (b) From Totally disabled (not able to work in any capacity) To (i) When do you consider the patient will be fit to return to work? Part time Full time Partially disabled (able to work in some capacity) in current occupation (i) Date patient was able to return to part time work (ii) If partially disabled, what duties is the patient unable to perform? Declaration and Authority I hereby certify that I have personally attended the above patient and that all the information supplied by me on this form is true and complete. I acknowledge that: this information is provided for the primary purpose of the assessment and investigation of a claim under a policy with (MLC); MLC may provide copies of this form to third parties, for example medical specialists or claims assessors from whom MLC seeks an independent report or to any other person deemed necessary to assist in the assessment or investigation of this claim. Name (please print) Qualifications (c) (iii) When do you consider the patient will be fit to return to work full time? No longer partially or totally disabled. When was the patient fit to return to work full time? 11 In respect of the patient s medical condition, have you completed any certificates for any other insurance company/ies or in connection with workers compensation, or government department (eg Centrelink, Department of Veterans Affairs)? No Go to question 12 To whom? 12 Any other comments which you believe are relevant to the assessment of this claim. Telephone number ( ) Signature Date Please attach copies of any reports and/or test results relating to the patient s current medical condition you may have in your possession. Return this form and any attachments to: Claims Department PO Box 200, North Sydney NSW MLC 06/09 Page 7 of 7 Income Protection Continuing Claim Form

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