RSA Personal Accident Insurance

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1 RSA Personal Accident Insurance Claim Form and Guidance Notes Call Save Number Customer Service Customer Complaints Procedure We are anxious to provide the highest quality of customer service at all times. We are eager therefore to learn about any aspect of our service or products not meeting customer expectations. If you have a complaint in connection with company service, the details of your policy or treatment of a claim please contact your insurance broker or contact our Customer Development and Service Manager, RSA Insurance Ireland Ltd, RSA House, Dundrum Town Centre, Sandyford Road, Dublin 16. Telephone no: (01) In the event of the issue not being resolved you may contact: The Insurance Information Service of the Irish Insurance Federation, 39 Molesworth St, Dublin 2. Telephone: (01) You may be eligible to take your complaint to the Financial Services Ombudsman's Bureau, 3rd Floor, Lincoln House, Lincoln Place, Dublin 2. Telephone: or (01)

2 DATA PROTECTION NOTICE RSA Insurance Ireland Ltd recognise that protecting personal information, including sensitive personal information, is very important and we recognise that our policyholders have an interest in how we collect, use and share such information. Please read the following carefully as it contains important information relating to the information that is provided to us in connection with this insurance policy, either by or on behalf of the policyholder. If information is provided relating to any individual, the Policyholder is responsible for obtaining the individual s consent to the use of their data in the manner outlined below. What does RSA do with Personal Data? Information provided will be used by RSA for the purposes of processing the application for insurance and administering the insurance policy. RSA may require sensitive data relating to individuals (such as medical, health or conviction data) in order to process the application and/or any claim made. By providing such data you explicitly consent to it being retained and used and verified by RSA for the purposes set out in this Notice. While RSA may disclose data to the policyholder and to any individuals related to the policy or their representatives, all information supplied will otherwise be treated in confidence by RSA. In particular, RSA will not disclose personal data to any third parties except a) to our agents, subcontractors and re-insurers b) to third parties involved in the assessment, administration or investigation of a claim, c) where consent has been received or d) where required or permitted by law. In order to provide policyholders with products and services this information will be held in the data systems of RSA or our agents or subcontractors. RSA may pass information to other companies for processing on our behalf. Some of these companies may be based outside the EEA, but in all cases RSA will ensure that its transfers of data are lawful and that information is kept securely and only used for the purposes for which it was provided. Calls to RSA may be recorded for quality assurance or verification purposes. Fraud prevention, detection & claims history In order to prevent and detect fraud and the non-disclosure of relevant information RSA may at any time: Share or verify information with companies within the RSA Insurance Group, other organisations outside the RSA Insurance Group including where applicable private investigators and public bodies including An Garda Síochána; Check and / or file details with fraud prevention agencies and databases, and if false or inaccurate information is given to us and we suspect fraud or a breach of a policy condition, we will record this. RSA may also search these agencies and databases to: a) Help make decisions about the provision, refusal and administration of insurance, credit and related services for the policyholder and/or any person relevant to the policy (e.g. named drivers). b) Trace debtors or beneficiaries, recover debt, prevent fraud and to manage accounts or insurance policies; c) Check identity to prevent money laundering, unless other satisfactory proof of identity is supplied to us; d) Undertake credit searches and additional fraud searches. Insurance Database Information about claims (whether by our customers or third-parties) made under policies that we provide is collected by us when a claim is made and is placed on an insurance industry database of claims known as Insurance Link. This information may be shared with other insurance companies, self insurers or statutory authorities. Insurance companies share claims data: a. to ensure that more than one claim cannot be made for the same personal injury or property damage b. to check that claims information matches what was provided when insurance cover was taken out c. and, when required, to act as a basis for investigating claims when our recorded information is incorrect or when we suspect that insurance fraud is being attempted. The purpose of Insurance Link is to help us identify incorrect information and fraudulent claims and, therefore, to protect customers. Guidelines for sharing information with other insurance companies, self-insuring organisations or statutory authorities are contained in the Data Protection Commissioner s Code of Practice on Data Protection for the Insurance Sector which is available at Under the Data Protection Acts 1988 and 2003 you have a right to know what information about you and your previous claims is held on Insurance Link. If you wish to exercise this right then please contact us at the address below. How to contact us: On payment of a small fee an individual is entitled to receive a copy of the information we hold about them and to seek rectification of any inaccurate data. If you have any questions, or you would like to find out more about this notice you can write to the Data Protection Officer, RSA Insurance Ireland Ltd, Dundrum Town Centre, Sandyford Road, Dundrum, Dublin 16. Please turn over 1

3 Personal Accident Claim Form How can we help you? We give claims our greatest possible care and try to deal with them as quickly as possible - because we know that this is important to you when you submit a claim. Please help us to help you by: making sure that the information you give is as clear and complete as possible remembering to sign and date this form Important Note: You must enclose estimates/valuations/receipts with this claim form. Ref No FOR ALL CLAIMS PLEASE COMPLETE THIS SECTION 1. Insured Name Mr/Mrs/Miss/Ms Policy No. Address: Occupation Telephone Number Home Business Please provide details of Age Height Weight At time of accident, were you gainfully employed? Yes No 2. General Name and Address of Doctor in attendance Note: Please ensure that Medical Certificate overleaf is completed by this Doctor Is he/she your usual Please state your VHI Policy Number (or any Private Health Insurance No.) Medical Attendant? Yes No Number: When can you be seen? Do you pay PRSI contributions? Yes No How long have you been (a) wholly unable to attend to any portion of your profession or occupation? from to (b) able to attend only partly to your profession or occupation? from to Names and Addresses of any other Insurer or Society or Club from which you are entitled to benefit in respect of the same accident/sickness 2

4 3. Details of Accident Place Date Time am/pm Please give full details of accident, indicating what you were doing at the time What injuries have you sustained? Have you previously suffered from similar injuries? Yes No If so, please give details Names and Addresses of witnesses When did incapacity start? Declaration I/we hereby declare that the above statements and information furnished by me/us on my/our behalf are true and complete in every respect. I/we have disclosed all information in my/our possession. I/we consent to all of our information being used, processed, disclosed and retained as set out in the Data Protection Notice above. I/we understand that RSA will pass the information on this form (and about any claim for which I/we may provide details) to Insurance Link where it will be available to other insurance companies. I/we consent to RSA contacting other insurance companies arising out of information contained on Insurance Link and to the other insurance company passing RSA information it has received about other claims involving anyone insured under the policy. Policyholder signature: X Date: 4. Medical Certificate This is to certify that Mr/Mrs/Miss/Ms is suffering from and * will/will probably be unfit to resume work until (*Delete as necessary) Disablement from attending to usual business or occupation commenced on Total disablement occurs when the Insured is wholly prevented from attending to his/her business or occupation whereas partial disablement shall mean disablement from a substantial part of the Insured person s usual occupation) If a date of return to work can be given, please complete the following Temporary total disablement from to Temporary partial disablement from to Is surgical intervention necessary or likely to be so? Yes No Is Insured Person confined to bed or house? Yes No On the basis of your existing knowledge and without undertaking any further examinations, is it your opinion that the disablement indicated above is solely attributable to the specified injury sustained? If not, please state below any contributing factors and the extent to which disablement is or has been thereby affected Signature and Qualification X NOTE FOR DOCTORS Any fee for this certificate is to be paid by the patient. Date Please return the completed form with the relevant evidence of the amount claimed. Notes for Policyholders Any fee for the medical certificate is payable by the Insured. Further medical certificates are required at fortnightly intervals during periods of disablement. Interim payments of benefits are normally made on request subject to satisfactory medical evidence. Insured may be required to submit to medical examination on behalf of and at the expense of RSA Insurance Ireland Limited in connection with any claim. 3

5 Please insert additional information here. 4

6 RS/CLA3019 (09/11) RSA, RSA House, Dundrum Town Centre, Sandyford Road, Dundrum, Dublin 16. Telephone: Facsimile: (01) RSA Insurance Ireland Limited is registered in Ireland under number with registered office at RSA House, Dundrum Town Centre, Sandyford Road, Dundrum, Dublin 16. RSA Insurance Ireland Limited is regulated by the Central Bank of Ireland.

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