WORKPLACE CAPITAL BENEFITS CLAIM FORM

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1 WORKPLACE CAPITAL BENEFITS CLAIM FORM OFFICE USE ONLY Claim Number Reference Number Complete this form if: You have suffered a workplace accident and wish to claim a capital benefit under the "Workplace Personal Accident Insurance Program" Forward this claim form to: TOTAL CLAIMS SOLUTIONS Level 1, 151 Rathdowne Street Carlton VIC 3053 For claim enquiries call: TOTAL CLAIMS SOLUTIONS (03) Instructions Section A The WORKER must complete ALL questions in Section A (pages 1-3) of the form. Incomplete answers and vague information will delay the assessment of your claim. Section B The worker s ATTENDING PHYSICIAN must complete Section B (pages 4-5) only if Section A is complete. Any charge for completion of this statement must be borne by the worker. Section C The worker s EMPLOYER must complete Section C (page 6) of this form. Important The ORIGINAL fully completed claim form must be sent with ALL DOCUMENTS outlined in the checklist. Checklist Impairment Notice Medical report(s) - if any WorkCover claim form - copy The issue of this form DOES NOT constitute admission of liability on our behalf. Section A WORKER DETAILS Incolink Member No. Union CFMEU CEPU AWU AMWU No Union Other Worker Surname Given name(s) Address (No PO Box) State Postcode Telephone Private Mobile D.O.B address Sex Male Female Marital status Single Married Defacto Height cm Weight Kg Occupation EMPLOYMENT DETAILS Name of Company Telephone Employment Status Casual Part-time Full time Apprentice What date did you commence employment with this company Are you still employed NO YES If No, when did you cease employment? ACCIDENT DETAILS Give the exact date and time the accident occurred : am/pm Detail the accident Detail the injuries sustained 1 of 6

2 ACCIDENT DETAILS - CONTINUED Did your accident occur on site? If Yes, please give details as to the job you were performing on the day Address where accident occurred Name & number of any witnesses to the accident Name of WorkCover Insurer 1. Name Telephone 2. Name Telephone Claim Number Name of Claims officer Telephone Fax Number Had you consumed any alcohol or drugs within the 8 hours prior to the accident No Yes If Yes, provide details Location Amount Have you had a similar condition before NO YES If Yes, give details of the physician, hospital or specialist attended. Doctor's Name Address Telephone attended YOUR PHYSICIAN S DETAILS Give the details of the first physician/hospital or specialist attending to you for this injury Doctor's Name Address Telephone attended Details of all other attending physicians and dates attended Doctor s name Address Telephone attended Who is your usual family doctor Doctor's name Address Telephone How long have you been receiving treatment or advice from this doctor Years Months PRIVACY QBE includes information about how we manage your personal information in our Product Disclosure Statements and Policy booklets. You can obtain a copy of the QBE Privacy Policy Statement from our website or contact the Compliance Manager on (02) or for further information. PAYMENT DETAILS If your claim is accepted, please advise what method you would like to receive payment. Cheque Electronic Fund Transfer (please provide your bank details) PLEASE NOTE: We depend on the accuracy of the details you are providing to us. Please write clearly and check with your bank if you are unsure of the bank details. Name of Bank Telephone BSB Number (6 digits) Bank Account Number Type of Bank Account i.e. Savings Name in which Account is held I, (name in full) Hereby authorise QBE Insurance (Australia) Limited and or Total Claims Solutions Pty Ltd to pay my benefits directly into my bank account. Signature Print Name 2 of 6

3 DECLARATION & AUTHORISATION - BY PERSON CLAIMING 1. I authorise any hospital, physician or other person who has attended me, or any employer, to give QBE Insurance (Australia) Limited or its representative any or all information with respect to my illness or injury, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. I also agree that copies of all employer records relevant to my claim including verification of earnings can be provided. 2. I give permission for QBE Insurance (Australia) Limited or its representative to obtain a copy of any police report with respect to my claim. 3. A photocopy of this authorisation will be considered as effective and valid as the original. 4. I understand that Total Claims Solutions Pty. Ltd act as claims managers on behalf of QBE Insurance (Australia) Limited. 5. I also authorise QBE Insurance (Australia) Limited, or its representatives, to give to and obtain from other insurers and/or statutory authorities, or their representatives, insurance reference bureaus and credit reporting agencies any information relating to my credit or insurance history as well as insurance claims information obtained during the course of this contract. 6. I also agree for Incolink to supply details of my employer payments to assist with my claim. 7. I also authorise QBE Insurance (Australia) Limited or its representative to refer my claim to Incolink s Member Service Department, if required. 8. I declare that the preceding statements and information are, to the best of my knowledge and belief, true in every aspect. 9. I understand the claim may be refused if information is not true or is withheld. The signatory must be authorised to sign on behalf of all named persons. Signature Print Name Acting as Claims Managers on behalf of QBE Insurance (Australia) Limited ABN of 6

4 Section B ATTENDING PHYSICIAN'S STATEMENT - TO BE COMPLETED BY YOUR TREATING DOCTOR / SURGEON *THE PATIENT WILL BE RESPONSIBLE FOR ANY FEE CHARGED TO COMPLETE THIS STATEMENT* Patient's Name Age Occupation Patient's address Exact nature of patient s injury. Please list in full detail all injuries the patient is disabled from *Please enclose COPIES of test RESULTS, IF ANY, which have determined the above diagnosis* Please select if the patient s injury resulted in any of the following: Permanent quadriplegia Permanent paraplegia Permanent and incurable paralysis of all limbs Third degree burns which cover more than 50% of the entire body Permanent physical severance or permanent total loss of use of the following: Both hands Both arms Both feet Both legs One hand and one foot One hand or one arm One foot or one leg Four fingers and one thumb Both joints of one thumb One joint of one thumb Three joints of one Two joints of one finger Permanent total loss of sight in one/both eyes Permanent total loss of the hearing in both ears Permanent total loss of lens of the one eye Permanent total loss of the hearing in one ear One joint of one finger All toes of one foot Great toe both joints Great toe one joint Each toe other than great Other conditions: Fractured leg or patella with established non-union Third degree burn which covers between 20% and 49% of the entire body Loss of at least 50% of all sound and natural teeth including capped or crown teeth per tooth The date of the patient's injury When did the patient first consult you for this injury When did the patient last consult you for this injury Did the patient sustain the accident at work? Please give details Give details of any circumstances such as the use of alcohol and or drugs, which may have caused or significantly contributed to the patient s accident. Please also include BAC readings, if taken How long have you known this person in a professional capacity Years Month Has patient ever had the same or a similar condition? If Yes, state when and describe whether this has an impact on current disablement Has the patient been hospitalised NO YES s to Name of hospital 4 of 6

5 ATTENDING PHYSICIAN'S STATEMENT - CONTINUED Have you provided any medical information to any other insurer regarding this injury? If Yes, please provide details and reports Insurer *PLEASE PROVIDE REPORTS - IF ANY* Name (Please Print) Address (Please Print) Telephone Fax Number address Medical Qualifications Signed 5 of 6

6 Section C EMPLOYER DETAILS - TO BE COMPLETED BY YOUR EMPLOYER Business/Trading name Incolink employer number Address State Telephone Fax number Postcode address Name of employee What is the employee s job classification (occupation) What is the employment status of the employee Casual Part-time Full time Apprentice State the employee's current gross weekly earnings (base rate of pay), as at the date of illness. Exclude overtime and allowances Standard hours worked per week hours Base hourly rate $ If Yes, please confirm the details of this claim Is the employee entitled to Workers Compensation benefits NO YES including a copy of the WorkCover Claim form Insurer Claim number Was the worker employed at the time of suffering the accident NO YES Address If Yes, provide address and worksite where worker was stationed prior to injury Worksite What date did the employee commence working for you The date the employee last worked for you, prior to the accident Has the employee returned to work NO YES If Yes, date returned I hereby declare the information I have provided on this form is, to the best of my knowledge and belief, true in every respect Officer s Name (Print) Position Telephone address Signature Total Claims Solutions Pty Ltd ABN Acting as Claims Managers on behalf of QBE Insurance (Australia) Limited Level 1, 151 Rathdowne Street, Carlton, Victoria 3053 T: (03) F: (03) T of 6

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