ACCIDENT INJURY SUPPORT TRUST

Size: px
Start display at page:

Download "ACCIDENT INJURY SUPPORT TRUST"

Transcription

1 ACCIDENT INJURY SUPPORT TRUST TE ROOPU O TE POU O PAKARARA Registration Pack Independent Support for ACC Clients 103 Frimley Avenue, Frimley, Hastings 4120 Phone: Fax: (06)

2 CLIENTS COPY Please keep for your information Dear Client, Included in this pack are our registration forms, authority forms as well as a questionnaire. Please fill out these forms and post them to us as soon as possible to the above address. Once we have received the information back from you we will request your ACC files, please note this can take up to 3 weeks. Once we have your ACC files, we will read them and contact you with the course of action that we will be taking. We will then make a first Appointment, at which we will discuss your claim. We do ask that at this first meeting, you bring any relative documents you may have from ACC including Decision letters. As well as the Registration Fee of $ Our account is ASB :00 Please include your name. We also want to make you aware that as on the membership registration form, it states that you wish to donate 10% of net payments you receive if you have a positive outcome from a review or appeal or other settlement process eg Lump Sum Payment or Back dated Weekly Compensation. All donations are tax deductible. Your support in this way enables us to provide a service to claimants such as yourself at minimum cost, and we would appreciate your willingness to contribute. We understand that this can be a stressful situation and we will get back to you in due course. Thank you. AIST Team Please refrain from cold calling, always ring for an appointment otherwise we cannot process all our claimants cases in a timely manner!

3 REGISTRATION DATE: File No NAME: DATE OF BIRTH: ADDRESS: TELEPHONE NUMBER: ADDRESS: SECOND POINT OF CONTACT PERSON & PHONE NO: ETHNICITY: HOW DID YOU HEAR ABOUT US? I understand that a registration fee of $ is payable on registration. ( Subject to the attached conditions) Costs: Our low cost service is designed for those who can not afford legal fees. Conditions do apply if you wish to enrol with the Accident Injury Support Trust see attached details. If you are represented at Mediation, Review or Appeal hearings, it is agreed that costs incurred and awarded for this representation (Apart from the claimants own expenses) shall be paid direct to the Access Legal Solutions Ltd Bank Account. Claimants will be requested to pay an additional Surcharge for Specialist reports or any GP charges for acquiring information that may be required to support Review and Appeal hearings at which you will be represented by Access Legal Solutions (NZ) Ltd We are a voluntary organization relying on donations to cover costs. If we are successful with obtaining entitlement for you, your donation would be appreciated. Note 1 Note 2 Note 3 Many claimants ask for guidelines relating to donations. See attached guide. All donations are tax deductible. All legal advocacy work relating to Reviews and Appeals will be carried out on your behalf by Access Legal Solutions (NZ) Ltd who will liaise with you at our premises. Advocacy charges for costs incurred on your behalf by Access Legal Solutions (NZ) Ltd will not exceed costs awarded at review or appeal. Entitlements as distinct from costs, are paid direct to claimants by ACC. Disclaimer: Accident Injury Support Trust will endeavour to provide relevant and accurate information to claimants on ACC matters. I understand that Accident Injury Support Trust takes no legal responsibility for matters relating to my claim. I accept the conditions outlined above. Signed: Date:

4 This Questionnaire will be held in confidence on your file; it is designed to help us to efficiently assist you with your claim. QUESTIONNAIRE Q1 Name: Q2 Who is your GP and address? Q3 ACC Claim No If Known: Q4 ACC Case Manager if Known: Q5 What is your injury/injury s that you require our assistance with? Q6 What date did this Injury occur? Q7 Please give a brief description of how you obtained your injury or the circumstances surrounding your injury?

5 Q8 Do you currently receive any assistance from ACC, if so what assistance? Q9 Do you receive any assistance from any other agencies? Q10 Have you seen any medical professionals other than your GP in relation to this injury? (If so please list their names if you can.) Q11 Please briefly describe what you would like us to achieve for you with regards to the outcome of your claim with ACC. Q12 Is there any other additional information you wish to advice us off? Have you already filed For Review or Appeal (if so, Please quote review number and include copies of all

6 correspondence Decision letters etc) PERMISSION TO ASSIST WITH HEALTH CARE PROVIDERS CONSENT TO COLLECT/RELEASE INFORMATION I. give consent for:..john Grove Julayne Barrett Margaret Grove Of Accident Injury Support Trust On behalf of Access Legal Solutions (NZ) Ltd, legal advocates, to assist me as a Support Person, with all matters relating to my treatment as a patient at the Hawkes Bay Healthcare Hospital and any other Health Care provider within New Zealand. Costs: If I am represented by ALS at Mediation, Review or Appeal hearings, I authorize costs awarded to be paid direct to the Access Legal Solutions (NZ) Ltd Bank Account.

7 Dated: Signed: PERMISSION TO ASSIST WITH ALL ACC & SENSITIVE CLAIMS CONSENT TO COLLECT/RELEASE INFORMATION I. Give consent for:..john Grove Julayne Barrett Margaret Grove of Accident Injury Support Trust On behalf of Access Legal Solutions (NZ) Ltd (ALS) to assist me as a Support Person and Agent with ALL ACC related matters such as ALL ACC & Sensitive Claim documents including a Claims Schedule and IA/LS history pertaining to ALL of my ACC Claims Note: To comply with ACC guidelines relating to Privacy issues, this authority stays in place till written advice of withdrawal by the client. Costs: If I am represented by ALS at Mediation, Review or Appeal hearings, I authorize costs awarded to be paid direct to the Access Legal Solutions (NZ) Ltd bank account. Dated:

8 Signed: Note: I understand that this CLIENT consent is CONTRIBUTION valid for the period GUIDE that the Accident Injury Support Trust provides assistance and support to me. ACC now require a fresh authority every 6 months. PERMISSION TO ASSIST WITH APPLICATIONS FOR REVIEWS & APPEALS I. Give consent for: John Grove Julayne Barrett Margaret Grove of Accident Injury Support Trust On behalf of Access Legal Solutions (NZ) Ltd to assist me as a Support Person and Agent with ALL ACC related matters such as APPLICATIONS FOR REVIEWS AND APPEALS pertaining to my case as appropriate. I give consent for a minimum period of 2 years. Costs: If I am represented by ALS at Mediation, Review or Appeal hearings, I authorize costs awarded to be paid direct to the Access Legal Solutions (NZ) Ltd Bank Account. I understand this allows ALS to apply for Reviews or Appeals on my behalf should ALS feel it necessary to do so.

9 I give full consent and accept that the ALS will always act in my best interests. Dated: Signed:

10 APPOINTMENT OF LEGAL ADVOCACY REPRESENTATIVE I.. HEREBY APPOINT Access Legal Solutions (NZ) Ltd to act as my legal representative at any Mediation, Review or Appeal hearings related to my Claim (s) with the Accident Compensation Corporation. It is agreed that costs incurred by me with ALS related to any Mediation, Review or Appeal shall be invoiced to me and recovered from any subsequent award of costs by Reviewers under the Review Costs Regulations of the Accident Compensation Act 2001 or by a Judge in the District Court. I direct that any such costs awarded be direct credited by the Accident Compensation Corporation to Access Legal Services (NZ) Ltd Bank Account I understand that Access Legal Solution (NZ) Ltd and it s staff take no legal responsibility for matters relating to my claim (s). Signed. Date.

11 ACC 5937 Authority to act Use this form to authorise someone to act on your behalf. YOUR DETAILS Client name: [Client full name] This form was completed on: [dd month yyyy] ACC number: [ACC number] Postal address: [Client postal address] Date of birth: [Client DOB] address: Home phone: Mobile phone: Work phone: AUTHORITY TO ACT DETAILS OF THE PERSON YOU ARE GIVING AUTHORITY TO ACT ON YOUR BEHALF. Full name: [Authorised person full name] Date of Birth: [DOB] Relationship to client: Address: [Authorised person postal address] Send all correspondence to this address. Please tick if you would like all correspondence to go to your authorised person. address: Home phone: Mobile phone: Work phone: ACCESS This authority to act covers (tick ONE only): Specific claim(s) only. Please list specific claim number(s): All claims, including future claims. This authority is valid until (tick ONE only): [dd month yyyy] Further notice. DECLARATION I authorise ACC to carry out or initiate transactions in accordance with this authority. I understand that ACC is not liable for any action done in accordance with this authority. I understand that this authority comes into effect from the date ACC receives and processes this form. I understand that I am giving my nominated person authority to access my information by telephone, , letter, fax or form. I understand that the cancellation of this authority must be made in writing or by telephone. Cancellation will not be effective until received and processed by ACC. SIGNATURE Client name: [Client full name] Date: Signature: The information collected on this form will only be used to fulfil the requirements of the Accident Compensation Act In the collection, use and storage of information, ACC will at all times comply with the obligations of the Privacy Act 1993 and the Health Information Privacy Code ACC5937 FEBRUARY 2012 PAGE 1 OF 1

12 CLIENT CONTRIBUTION GUIDE (Keep for your records) Due to the changing economic climate we have experienced a down turn in funding from Community Funding Groups on whom we depend to provide a low cost service. Please note that while we provide a low cost service, in that we don t charge an hourly fee for our time, we do ask clients to provide a contribution from entitlements received from ACC following our intervention on your behalf. Revoked decision prior to Review $150 Revoked decision prior to Appeal $250 Reinstatement of Weekly Compensation $250 Accepted Surgery Requests $500 Payment of back dated Independence Allowance Lump Sum or Weekly Compensation 10% Photocopying costs for Reviews & Appeals Suggested Contributions PLEASE NOTE: ALL CONTRIBUTIONS CAN BE CLAIMED FOR ON AN IR526 FORM AND YOU WILL RECEIVE 33.33% BACK OF YOUR DONATION e.g. $150 DONATION, YOU WILL RECEIVE $50 BACK!! THIS GUIDE WILL NATURALLY DEPEND ON EACH INDIVIDUAL CASE AND SITUATION. WE RUN TOTALLY ON FUNDING AND DONATIONS AND WITH THE ECONOMY THE WAY IT IS, WE RELY MORE NOW THAN EVER ON CLIENTS DONATING DUE TO THE LACK OF FUNDING AVAILBLE. WITHOUT THIS WE CAN NOT CONTINUE TO HELP CLIENTS AS WE HAVE SUCCESSFULLY HELPED TO DATE! Please note: The requested donations above are separate from your individual responsibility of costs when obtaining fresh medical opinions and GP notes etc. Please also note that when you are requested to obtain certain information for the office that this is done in a timely manner to ensure that consistent flow is made with your case. WITH THANKS THE AIST TEAM

First Notice of Claim for Illness or Injury

First Notice of Claim for Illness or Injury How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents required Section A: Statement of claimant

More information

Payment Protection Insurance Claim Form

Payment Protection Insurance Claim Form Claim Form All forms to be completed, signed and returned to: FREEPOST RSAX GKEK HUYK Reclaim Your PPI Ltd Waters Green House Sunderland Street Macclesfield SK11 6LF Please complete the following forms

More information

First Notice of Claim for Unemployment Benefits

First Notice of Claim for Unemployment Benefits How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Involuntary Unemployment claims - Documents required Section A: Statement of claimant

More information

Financial Claims Specialists Ltd T/A Finance Claims. Terms and Conditions for the Provision of Services

Financial Claims Specialists Ltd T/A Finance Claims. Terms and Conditions for the Provision of Services Financial Claims Specialists Ltd T/A Finance Claims Terms and Conditions for the Provision of Services IMPORTANT: These terms and conditions form part of a legally binding contract and you should read

More information

Please enclose a copy of your loan/credit agreement if available. For credit cards, please enclose a copy of your statement.

Please enclose a copy of your loan/credit agreement if available. For credit cards, please enclose a copy of your statement. Claim Forms Please print, complete and return to: Moneyback PPI Basepoint Business Centre Unit 106 Canada House 272 Field End Rd Eastcote Middlesex HA4 9NA Please enclose a copy of your loan/credit agreement

More information

First Notice of Claim for Unemployment Benefits

First Notice of Claim for Unemployment Benefits How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Involuntary unemployment claims - documents required Section A: Statement of claimant

More information

Please enclose a copy of your loan/credit agreement if available. For credit cards, please enclose a copy of your statement.

Please enclose a copy of your loan/credit agreement if available. For credit cards, please enclose a copy of your statement. Claim Forms Please print, complete and return to: Moneyback PPI Basepoint Business Centre Unit 106 Canada House 272 Field End Rd Eastcote Middlesex HA4 9NA Please enclose a copy of your loan/credit agreement

More information

PERSONAL ACCIDENT CLAIM FORM - MEMBERS

PERSONAL ACCIDENT CLAIM FORM - MEMBERS Pony Club Insurance Scheme PERSONAL ACCIDENT CLAIM FORM - MEMBERS Please read this page before completing the Claim Form Dear Member Thank you for your Claim Form request. This letter contains important

More information

Mis-Sold Payment Protection Insurance (PPI) Claims Pack

Mis-Sold Payment Protection Insurance (PPI) Claims Pack Mis-Sold Payment Protection Insurance (PPI) Claims Pack Debt Clear Solutions is delighted to enclose an information and application pack that will enable us to reclaim any mis-sold Payment Protection Insurance

More information

Guide to completing this claim form

Guide to completing this claim form Credit Card Insurance Claim Form Guide to completing this claim form For each type of claim there are different requirements and different sections of this form that you need to complete. To help us process

More information

CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH

CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH Seafarers Rehabilitation and Compensation Act 1992 Information about claiming compensation In this document, all references to the employer mean the employer

More information

Claim Forms. Please print, complete and return to (no stamp needed):

Claim Forms. Please print, complete and return to (no stamp needed): Claim Forms Please print, complete and return to (no stamp needed): Claims Thru Us Freepost RRZK-YTRL-UEXT 1 Farnsworth Court West Parkside LONDON SE10 0QF Please enclose a copy of your loan/credit agreement

More information

Lump sum benefit payment request for your superannuation or account based pension

Lump sum benefit payment request for your superannuation or account based pension Lump sum benefit payment request for your superannuation or account based pension How to claim a benefit To claim a benefit you will need to complete the attached Benefit Payment Request and send it direct

More information

ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A.

ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. ATTORNEYS JO ANN HOFFMAN & VANCE B. MOORE, P.A. MAIN OFFICE: 4403 West Tradewinds Avenue Phone: (954) 772-2644 Lauderdale-By-The-Sea, Florida 33308 Fax: (954) 772-2845 attorneysjoannhoffman@gmail.com AUTHORIZATION

More information

SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM

SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM The issue or acceptance of this form is not construed as an admission of liability on the part of the Company. Please print clearly. To avoid delays please

More information

Information sheet Pre-Action Protocol for Low Value Personal Injury (Employers Liability and Public Liability) Claims

Information sheet Pre-Action Protocol for Low Value Personal Injury (Employers Liability and Public Liability) Claims Information sheet Pre-Action Protocol for Low Value Personal Injury (Employers Liability and Public Liability) Claims You have received this information sheet as it is likely that your claim will proceed

More information

Second owner. Postal address. Email address. a) Are you notifying a change of address? Y N

Second owner. Postal address. Email address. a) Are you notifying a change of address? Y N Claim Form Medical Private Medical Cover Policy number 1.0 Life assured s details Title Surname First name(s) Male Female of birth Street address Suburb Town/city Postcode Postal address (if different

More information

Claim for Compensation for a Work-related death

Claim for Compensation for a Work-related death SRC 184 (March 2014) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act)

More information

Personal Accident & Sickness Claim Form IMPORTANT NOTES

Personal Accident & Sickness Claim Form IMPORTANT NOTES Personal Accident & Sickness Claim Form IMPORTANT NOTES PRIVACY STATEMENT In this Privacy section we, us or our means Great Lakes Australia and Winsure, unless specified otherwise. CONTACT US We are committed

More information

Personal Injury Claim Form

Personal Injury Claim Form Personal Injury Claim Form A.I.D.K.A AUSTRALIAN INDEPENDENT DIRT KART ASSOCIATION POLICY NUMBER 5494580 Correct completion of these forms will assist us to make accurate and faster decisions regarding

More information

First Notice of Claim for Illness or Injury

First Notice of Claim for Illness or Injury First Notice of Claim for Illness or Injury How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents

More information

First Notice of Claim for Unemployment Benefits

First Notice of Claim for Unemployment Benefits How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Involuntary Unemployment claims - Documents required Section A: Statement of claimant

More information

General Terms and Conditions of MarktOnderzoekAssociatie Nederland (MOA) as applicable to the carrying out of assignments to conduct market research

General Terms and Conditions of MarktOnderzoekAssociatie Nederland (MOA) as applicable to the carrying out of assignments to conduct market research General Terms and Conditions of MarktOnderzoekAssociatie Nederland (MOA) as applicable to the carrying out of assignments to conduct market research Article 1 - General 1.1. These general terms and conditions,

More information

TEMPLE LITIGATION ADVANTAGE INSURANCE FOR DISBURSEMENTS AND OPPONENT S COSTS Certificate of Insurance

TEMPLE LITIGATION ADVANTAGE INSURANCE FOR DISBURSEMENTS AND OPPONENT S COSTS Certificate of Insurance TEMPLE LITIGATION ADVANTAGE INSURANCE FOR DISBURSEMENTS AND OPPONENT S COSTS Certificate of Insurance In return for the payment of the Premium specified in the Schedule and based on any Information that

More information

2. For cancellation or amendment of travel arrangements due to you or your relatives illness /death (Complete Sections A, C D and E)

2. For cancellation or amendment of travel arrangements due to you or your relatives illness /death (Complete Sections A, C D and E) IMPORTANT: please read this before you start Use the check list below to help you complete your claims form, and identify you will need to attach. We don t want you to miss something. Delays can occur

More information

CREDIT ACCOUNT APPLICATION including TERMS OF TRADE

CREDIT ACCOUNT APPLICATION including TERMS OF TRADE Handbook 11 v 5 PWAGRIFFIN LIMITED CREDIT ACCOUNT APPLICATION including TERMS OF TRADE PWAGRIFFIN LIMITED CUSTOMER INFORMATION; CREDIT APPLICATION; TERMS OF TRADE CUSTOMER (Trading Name) (If a partnership,

More information

Previous names Male Female Date of birth. Second owner. Postal address. Email address. a) Are you notifying a change of address?

Previous names Male Female Date of birth. Second owner. Postal address. Email address. a) Are you notifying a change of address? Claim Private Medical Cover Policy number 1.0 Life assured s details Previous names Male Female of birth Place of birth Street address Suburb Postal address (if different from above) Business phone ( )

More information

FUNERAL PLAN Insurance

FUNERAL PLAN Insurance FUNERAL PLAN Insurance Covering you co-operatively An insurance plan to provide you and your family with peace of mind at a difficult time. FUNERAL PLAN Peace of mind at a difficult time The death of a

More information

Legal Assistance (Personal Injury) Claim Form (NIPSA Member)

Legal Assistance (Personal Injury) Claim Form (NIPSA Member) Part 1 About your membership 1. Surname: Form LS2 Legal Assistance (Personal Injury) Claim Form (NIPSA Member) 2. Forename(s): (in full) 3. Branch No. 4. Membership No. 5. National Insurance No. For NIPSA

More information

Business Card Application Form

Business Card Application Form Business Card Application Form Apply for your PGG Wrightson Rewards Business Card today and start earning the Rewards you deserve! Looking for a convenient way to manage your business spending needs while

More information

PPI Claim Form. Easy steps to claim back your money. 1. Fill in all the required details and questionnaire.

PPI Claim Form. Easy steps to claim back your money. 1. Fill in all the required details and questionnaire. PPI Claim Form Easy steps to claim back your money. 1. Fill in all the required details and questionnaire. 2. Sign and date the Terms of Service and Letter of Authority where you see the Joint policies

More information

LEADR Members. Professional indemnity insurance and public liability insurance. Proposal form 2014-2015

LEADR Members. Professional indemnity insurance and public liability insurance. Proposal form 2014-2015 LEADR Members Professional indemnity insurance and public liability insurance Proposal form 2014-2015 Please return completed proposal form to: Aon Risk Services Australia Limited ABN 17 000 434 720 Levels

More information

All intellectual property rights and copyright in the material on this website belongs to The Entitlements Agency, unless otherwise stated.

All intellectual property rights and copyright in the material on this website belongs to The Entitlements Agency, unless otherwise stated. Terms & Conditions Using our Services The Entitlements Agency has designed this website with the idea of offering you a source of information. Whilst we endeavour to maintain the site and keep the information

More information

Income Protection Continuing Claim Form

Income Protection Continuing Claim Form MLC Insurance Income Protection Continuing Claim Form MLC Nominees Pty Limited ABN 93 002 814 959 AFSL 230702 RSE L0002998 The Universal Super Scheme ABN 44 928 361 101 R1056778 Superannuation Fund Number

More information

Clinical Negligence: A guide to making a claim

Clinical Negligence: A guide to making a claim : A guide to making a claim 2 Our guide to making a clinical negligence claim At Kingsley Napley, our guiding principle is to provide you with a dedicated client service and we aim to make the claims process

More information

APPLICATION FOR. License Fee Only. Non- NZTA

APPLICATION FOR. License Fee Only. Non- NZTA C4:08-15 NEW ZEALAND THOROUGHBRED RACING INC PO Box 38386, WMC Telephone: (04) 576 6240 Facsimile: (04) 568 8866 Web: www.nzracing.co.nz Email: licensing@nzracing.co.nz APPLICATION FOR Non- NZTA License

More information

When we receive your claim submission, we will assess it and correspond with you further in due course.

When we receive your claim submission, we will assess it and correspond with you further in due course. Travel Insurance Boots Travel Claims PO Box 60108 London SW20 8US Tel: 0845 125 3820 Fax: 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you

More information

Your People, Protected. Sports group Personal Accident Claim Form

Your People, Protected. Sports group Personal Accident Claim Form Your People, Protected Sports group Personal Accident Claim Form Sports group Personal Accident/Claim Form 2 Claim Form Dear Member, IMPORTANT INFORMATION, relevant to YOUR Claim, is contained on this

More information

Operational Guideline Compensation Recovery of NDIS Amounts Action has not Been Commenced to Recover Compensation

Operational Guideline Compensation Recovery of NDIS Amounts Action has not Been Commenced to Recover Compensation Operational Guideline Compensation Recovery of NDIS Amounts Action has not Been Commenced to Recover Compensation Legislation 1. Read ss.104, 105 and 105A of the National Disability Insurance Scheme Act

More information

Dear Participant, If you have any questions, please call the Customer Service Office at 702-733-9938. Sincerely, Culinary Health Fund

Dear Participant, If you have any questions, please call the Customer Service Office at 702-733-9938. Sincerely, Culinary Health Fund 1901 Las Vegas Blvd. So. Suite 107 Las Vegas, Nevada 89104-1309 (702) 733-9938 www.culinaryhealthfund.org Dear Participant, We have been informed that you and/or your dependent(s) have been involved in

More information

PPI Customer Information Handbook

PPI Customer Information Handbook PPI Customer Information Handbook 1 Contents 1. Welcome - Page 3 2. What Happens Next - Page 4 3. Terms & Conditions - Pages 5-12 4. Complaints Handling Procedure - Page 13 5. Cancellation Procedure -

More information

CLAIMLINE UK LTD GENUINE NO WIN NO FEE CLAIMS

CLAIMLINE UK LTD GENUINE NO WIN NO FEE CLAIMS YOUR PERSONAL MISSELLING PPI CLAIMS PACK CLAIMLINE UK LTD GENUINE NO WIN NO FEE CLAIMS Regulated by the Ministry of Justice in respect of Claims Management Activities Ministry of Justice Authorisation

More information

Group Salary Continuance. A. Disability Details. Scheme Name or Employer (Business) Name

Group Salary Continuance. A. Disability Details. Scheme Name or Employer (Business) Name Group Salary Continuance Continuing Claim Form ABN 90 000 000 402 AFSL 230694 Please fully complete this claim form (pages 1 to 5). If there is insufficient space to fully answer a question, please use

More information

TICKETMASTER SINGLE EVENT TICKETING AGREEMENT. Ticketmaster NZ Limited. ( Ticketmaster ) and. ( Client )

TICKETMASTER SINGLE EVENT TICKETING AGREEMENT. Ticketmaster NZ Limited. ( Ticketmaster ) and. ( Client ) TICKETMASTER SINGLE EVENT TICKETING AGREEMENT between Ticketmaster NZ Limited ( Ticketmaster ) and ( Client ) Event Venues THIS AGREEMENT is made the 2011. BETWEEN TICKETMASTER NZ LIMITED, Level 1, Citibank

More information

AAMT Massage Therapist Proposal Form Combined Malpractice, Public and Products Liability Insurance effective 30 September 2015

AAMT Massage Therapist Proposal Form Combined Malpractice, Public and Products Liability Insurance effective 30 September 2015 Page 1 of 5 AAMT Proposal Form Combined Malpractice, Public and Products Liability Insurance effective 30 September 2015 Please complete and return this proposal form via post, email or fax using the contact

More information

Claim Forms Please print, complete and return to:

Claim Forms Please print, complete and return to: Claim orms Please print, complete and return to: Moneyback PPI Basepoint Business Centre Canada House 272 ield End Rd Eastcote Middlesex HA4 9NA Please complete a separate Part 2 and Part 3 for each account.

More information

Please complete the Account Details page of our pack and ONE Letter of Authority for each company you want to claim against.

Please complete the Account Details page of our pack and ONE Letter of Authority for each company you want to claim against. Please complete the Account Details page of our pack and ONE Letter of Authority for each company you want to claim against. Q. I don t have any account numbers or documentation, can I still claim? A.

More information

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment.

If you miss 3 consecutive appointments we may have to notify your physician and will require a new referral in order to continue your treatment. Welcome to POST Physical Therapy Brookline. We strive to provide our patients with excellent service and quality care. Our commitment to your well-being and health care is something that we at POST Physical

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: AN A038364 PAD Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TRIATHLON AUSTRALIA V-Insurance Group Pty Ltd Level 28, Angel Place, 123 Pitt Street, SYDNEY

More information

SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form

SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form Dear Member, Thank you for your Claim Form request. This letter contains important information relevant to your

More information

Information Form. Personal Information. 2nd Applicant. First Names. Surname. Address

Information Form. Personal Information. 2nd Applicant. First Names. Surname. Address No Win, No Fee Information Form Personal Information 1st 2nd Mr/Mrs/Miss/Ms/Title Date of Birth Mr/Mrs/Miss/Ms/Title Date of Birth Telephone Number Telephone Number Mobile Mobile Best Contact Time Best

More information

Getting help and what to know if you ve been injured at work

Getting help and what to know if you ve been injured at work Getting help and what to know if you ve been injured at work Introduction If you ve been injured at work, this guide provides you with useful information to help you recover from your injury. Once you

More information

Individual. Appointed Introducer s Agreement. Between. Paragon Insurance Services Ltd. 513 Crown House. North Circular Road. London NW10 7PN.

Individual. Appointed Introducer s Agreement. Between. Paragon Insurance Services Ltd. 513 Crown House. North Circular Road. London NW10 7PN. Individual Appointed Introducer s Agreement Between Paragon Insurance Services Ltd 513 Crown House North Circular Road London NW10 7PN and Name of Appointed Representative Address... Paragon Insurance

More information

Application for Tertiary Education Withdrawal

Application for Tertiary Education Withdrawal For assistance with completing this form please go to www.whairawa.com, or contact us on 0800 WHAI RAWA (0800 942 472). Please note processing of request will normally take up to five working days from

More information

Pages 1 4 to be completed by the legal guardian and pages 7 10 to be completed by the treating doctor.

Pages 1 4 to be completed by the legal guardian and pages 7 10 to be completed by the treating doctor. Kids Claim Form Pages 1 4 to be completed by the legal guardian and pages 7 10 to be completed by the treating doctor. We ll assess your claim as quickly as possible. The information you provide will help

More information

DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES

DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM PO Box 2717 Taren Point NSW 2229 Telephone: 1300 188 299 Facsimile: 1300 662 215 Email: claims@dawes.com.au www.dawes.com.au Before completing this claim

More information

CONTINGENCY FEE CONTRACT

CONTINGENCY FEE CONTRACT CONTINGENCY FEE CONTRACT THIS IS AN AGREEMENT between, hereafter referred to as "Client," and the Law Offices of, PLC, hereafter referred to as "Attorney." 1. Matter Covered: Client retains Attorney to

More information

d d mm y y If the injury was as a result of criminal assault or a Road Traffic Accident, was the accident reported to the police?

d d mm y y If the injury was as a result of criminal assault or a Road Traffic Accident, was the accident reported to the police? Personal Accident Claim Form This form has been designed to help you provide all the information we need to process your claim quickly. Failure to complete this form correctly may delay your claim. We

More information

MYOB Professional Partner Public Accountant

MYOB Professional Partner Public Accountant MYOB Professional Partner Public Accountant Partner Benefits FACTSHEET As an accountant in public practice, you know how important it is for your practice to keep pace with the ever-changing technology

More information

BUPA BY YOU YOUR MEMBERSHIP GUIDE

BUPA BY YOU YOUR MEMBERSHIP GUIDE BUPA BY YOU YOUR MEMBERSHIP GUIDE bupa.co.uk ABOUT THIS GUIDE Welcome to your Bupa By You guide. We know that insurance can be hard to follow. That s why we ve made this guide as simple as possible. You

More information

GUIDE TO FUNDING YOUR MEDICAL NEGLIGENCE CLAIM

GUIDE TO FUNDING YOUR MEDICAL NEGLIGENCE CLAIM GUIDE TO FUNDING YOUR MEDICAL NEGLIGENCE CLAIM Because of the expert knowledge and depth of investigation required in order to bring a successful claim, negligence litigation can be expensive. Understandably,

More information

DETERMINATION FOR PREVIOUS HOME OWNER FORM

DETERMINATION FOR PREVIOUS HOME OWNER FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL/ APPLICATION FORM and KiwiSaver First-Home Withdrawal DETERMINATION FOR PREVIOUS HOME OWNER FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL/APPLICATION

More information

PENSION ENCASHMENTS AND SMALL POTS ADVISED NON-GMP CASES

PENSION ENCASHMENTS AND SMALL POTS ADVISED NON-GMP CASES PENSION ENCASHMENTS AND SMALL POTS ADVISED NON-GMP CASES IMPORTANT INFORMATION Please read this section carefully before completing this application form. This form can only be used where you are taking

More information

JLT SPORT ASSET PROTECT CLAIM FORM

JLT SPORT ASSET PROTECT CLAIM FORM JLT SPORT ASSET PROTECT CLAIM FORM PLEASE USE BLOCK LETTERS WHILE COMPLETING THIS FORM CLAIMS HOTLINE: 1800 640 009 or call direct: (08) 8235 6455 Please forward your completed claim form to: Echelon Claims

More information

Members of the Institute of Arbitrators & Mediators of Australia (IAMA) Professional indemnity insurance and public liability insurance

Members of the Institute of Arbitrators & Mediators of Australia (IAMA) Professional indemnity insurance and public liability insurance Members of the Institute of Arbitrators & Mediators of Australia (IAMA) Professional indemnity insurance and public liability insurance Proposal form 2014-2015 Please return completed proposal form to:

More information

CONTINGENCY FEE RETAINER AGREEMENT. This contingency fee retainer agreement is. Tel: 905 850 2642 Fax: 905 850 8544 Toll Free: 1-866-850 2642.

CONTINGENCY FEE RETAINER AGREEMENT. This contingency fee retainer agreement is. Tel: 905 850 2642 Fax: 905 850 8544 Toll Free: 1-866-850 2642. CONTINGENCY FEE RETAINER AGREEMENT This contingency fee retainer agreement is B E T W E E N : POTESTIO LAW FIRM 401 Bay Street, Suite 1400 Toronto ON M5H 2Y4 Tel: 905 850 2642 Fax: 905 850 8544 Toll Free:

More information

Conditional Fee Agreement ( CFA ) [For use in personal injury and clinical negligence cases only].

Conditional Fee Agreement ( CFA ) [For use in personal injury and clinical negligence cases only]. Disclaimer This model agreement is not a precedent for use with all clients and it will need to be adapted/modified depending on the individual clients circumstances and solicitors business models. In

More information

Community Underwriting Personal Accident Claim Form

Community Underwriting Personal Accident Claim Form Community Underwriting Personal Accident Claim Form About Community Underwriting Community Underwriting Agency Pty Ltd (Community Underwriting) acts under a binding authority as Agent for Berkley Insurance

More information

Australian Superannuation Transfer Guide

Australian Superannuation Transfer Guide Australian Superannuation Transfer Guide Contents Page Making an informed decision 3 How do I know if I have Super in Australia? 3 How do I know if my Australian Super can be transferred? 4 Why should

More information

TOP THINGS TO REMEMBER ABOUT THE TRUSTEE S OFFICE AND YOUR CHAPTER 13 CASE

TOP THINGS TO REMEMBER ABOUT THE TRUSTEE S OFFICE AND YOUR CHAPTER 13 CASE TOP THINGS TO REMEMBER ABOUT THE TRUSTEE S OFFICE AND YOUR CHAPTER 13 CASE 1. Know your case number. 2. Make your payments. Send your payments in time for the payments to reach the Trustee s office by

More information

Terms and Conditions

Terms and Conditions Terms and Conditions We want your decision to use Valour Financial Management services to be the best decision you have ever made towards regaining control of your financial situation. To that end we aim

More information

DRAFT MOTOR TRAFFIC (THIRD- PARTY INSURANCE) (COST RECOVERY) (JERSEY) REGULATIONS

DRAFT MOTOR TRAFFIC (THIRD- PARTY INSURANCE) (COST RECOVERY) (JERSEY) REGULATIONS STATES OF JERSEY r DRAFT MOTOR TRAFFIC (THIRD- PARTY INSURANCE) (COST RECOVERY) (JERSEY) REGULATIONS 201- Lodged au Greffe on 13th December 2012 by the Minister for Health and Social Services STATES GREFFE

More information

Investment Dealing Account. Corporate Application form for advised clients only

Investment Dealing Account. Corporate Application form for advised clients only Investment Dealing Account Corporate Application form for advised clients only How to complete this form Your adviser can also apply on your behalf for an Investment Dealing Account online at www.alliancetrustsavings.co.uk/adviser

More information

HEARTLAND BANK HEARTLAND HOME EQUITY LOAN LOAN DETAILS

HEARTLAND BANK HEARTLAND HOME EQUITY LOAN LOAN DETAILS HEARTLAND BANK HEARTLAND HOME EQUITY LOAN LOAN DETAILS Sentinel Custodians Limited (Sentinel) of Level 1, 87 Hurstmere Road, Takapuna, Auckland 0622 offers you a Heartland Home Equity Loan on the terms

More information

Optimum Performance Physical Therapy, LLC

Optimum Performance Physical Therapy, LLC Optimum Performance Physical Therapy, LLC Patient Information: Name: DOB: SS# Address: Phone: (H) (W) (C) Sex: Male Female Marital Status: M S D W Email: Employer Name/ Address: Referring Physician: (P)

More information

ACC AUDIT GUIDELINES - INJURY MANAGEMENT PRACTICES

ACC AUDIT GUIDELINES - INJURY MANAGEMENT PRACTICES ACC AUDIT GUIDELINES - INJURY MANAGEMENT PRACTICES Guidelines to understanding the audit standards for the Injury Management Section of the ACC Partnership Programme Please note: There is a separate guideline

More information

135 West Bay Street, Suite 400 Jacksonville, FL 32202 Phone: (904)598 1110 or (877)596 5705 Fax: (904)598 1081 erin@deltasettlements.

135 West Bay Street, Suite 400 Jacksonville, FL 32202 Phone: (904)598 1110 or (877)596 5705 Fax: (904)598 1081 erin@deltasettlements. MSA ALLOCATION PROCESS Please submit the following items for the determination of your Medicare Set-Aside Allocation: 1. Completed Intake Form (attached) 2. Signed Consent to Release for CMS (attached)

More information

VISITORS COVER CLAIM FORM AND MEDICAL CERTIFICATE

VISITORS COVER CLAIM FORM AND MEDICAL CERTIFICATE VISITORS COVER CLAIM FORM AND MEDICAL CERTIFICATE CLAIM FORM Before you complete this claim form: did you know that you may be able to submit your claim for selected services online at bupa.com.au? (terms

More information

Terms and Conditions. Our Services Explained

Terms and Conditions. Our Services Explained Our Services Explained Winn Solicitors provide a one-stop-shop service for innocent victims of road traffic accidents and other accidents, who need help to recover compensation and/or other services. In

More information

Claim for Compensation for a Work-related death

Claim for Compensation for a Work-related death SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the

More information

NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance

NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance Brokers Ltd have arranged an insurance policy designed to

More information

How Do You Get Your Money? Simply fill in the enclosed claim pack and send it back to us in the pre-paid envelope provided.

How Do You Get Your Money? Simply fill in the enclosed claim pack and send it back to us in the pre-paid envelope provided. For no-hassle Payment Protection Insurance (PPI) Claims 2 The Old Stables, Mitton Road, Whalley, Clitheroe, BB7 9PA telephone 01254 822880 email: info@yourmoneyclaim.co.uk Welcome to Your Money Claim,

More information

Have you been mis-sold a Packaged Bank Account? We are dedicated to dealing with claims where you have been mis-sold a packaged bank account

Have you been mis-sold a Packaged Bank Account? We are dedicated to dealing with claims where you have been mis-sold a packaged bank account Have you been mis-sold a Packaged Bank Account? We are dedicated to dealing with claims where you have been mis-sold a packaged bank account Welcome to Your Money Claim, We all know about mis-sold PPI,

More information

Business Online Application Form

Business Online Application Form Business Online Application Form All sections apart from SEVEN, EIGHT & NINE must be completed. If you have any questions about this form please contact your Business Banker or Westpac branch. SECTION

More information

Important information about your savings account

Important information about your savings account Important information about your savings account Important information about your savings account 1 Thank you for opening a Kent Reliance savings account. This leaflet contains information to help you

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: SUA/002202 Claim Number: Willis Australia Limited ABN 90 000 321 237 AFS 240600 PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TRIATHLON AUSTRALIA Willis Australia Limited

More information

Smart Support Services (Sheffield) Ltd.

Smart Support Services (Sheffield) Ltd. Payroll & Managed Accounts Specialists in Health & Social Care MANAGED ACCOUNTS APPLICATION FORM / SERVICE AGREEMENT & Ts & Cs Valid from 01/04/2014 (MA: V12, 11/07/2014) This form can be made available

More information

PATIENT REGISTRATION Date:

PATIENT REGISTRATION Date: PATIENT REGISTRATION Date: PLEASE PRESENT YOUR DRIVER S LICENSE AND INSURANCE CARDS TO RECEPTION DESK. INSURANCE CO-PAYMENTS ARE EXPECTED BEFORE SERVICES ARE RENDERED. PAYMENT IN FULL IS EXPECTED WHEN

More information

Project Application Form All work other than Multiple Dwelling Projects

Project Application Form All work other than Multiple Dwelling Projects HBCF HOME BUILDING COMPENSATION FUND Section 1 - Builder Information Project Application Form All work other than Multiple Dwelling Projects This application is to be completed by Builders & Contractors

More information

Compensation. Chapter 11. Payment of compensation

Compensation. Chapter 11. Payment of compensation Compensation Chapter Payment of COMP : Payment of Section.1 : Application and Purpose.1 Application and Purpose.1.1 R Application This chapter applies to the FSCS..1.2 G It is also relevant to claimants..1.3

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: 0028332 Claim Number: s PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TENPIN BOWLING AUSTRALIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised

More information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: ATCSI00035 Claim Number: PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TABLE TENNIS AUSTRALIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised

More information

Trinity Forces Personal Injury Legal Protection

Trinity Forces Personal Injury Legal Protection trinity Forces PERSONAL INJURY LEGAL PROTECTION Trinity Forces Personal Injury Legal Protection From the specialist you can trust POLICY WORDING FEBRUARY 2015 www.trinity-ins.com 2 PERSONAL INJURY LEGAL

More information

AFSA CREDIT APPLICATION

AFSA CREDIT APPLICATION AFSA CREDIT APPLICATION Privacy The information on this form is collected and used for the primary purpose of transacting with AFSA. AFSA s privacy policy explains how personal information is managed.

More information

Blue Care Income Protection Claim Form

Blue Care Income Protection Claim Form Blue Care Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields

More information

Application Form and Insurance Information

Application Form and Insurance Information Application Form and Insurance Information Family Day Care Australia Educator Insurance 9 Insurance Application Form C A O OFFICE USE ONLY Applicant Details Name of family day care coordination unit you

More information

Helping Union Members

Helping Union Members Helping Union Members with their ACC Claims A Guide for Union Delegates and Health and Safety Representatives The Code of ACC Claimants Rights The Code of ACC Claimants Rights guides how ACC works with

More information