CLAIMFORM ILLNESS/CONDITION

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Jody French
8 years ago
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1 CLAIMFORM ILLNESS/CONDITION HEALTH INSURANCE Danica Pension Parallelvej 17 DK-2800 Kgs. Lyngby Denmark Telephone Policy Name CPR-. Address Tel. Mobile To be filled in by the insured. All questions must be answered. Your insurance cover is detailed in your statement of cover and in the insurance conditions. 1. Which illness/condition or symptoms do you have? 2. Is the illness/condition/symptoms the result of an accident? If yes a: When did the accident happen? b: What happened and what was the direct cause? Time: 3. c: Has a police report been filed? d: Was a blood alcohol content test performed? Which police station: When did you first notice any symptoms of the 4. Have you consulted your usual doctor because of the illness/condition/symptoms? 5. Have you been examined by another doctor/treatment provider/hospital/emergency room because of the illness/condition/symptoms? 6. Who is your usual doctor? 7. Have you suffered from the same or a similar illness/ condition before? If yes: a: Were you examined by a health care worker? DAN90404ENG b: What treatment did you receive? c: Who treated you? Forsikringsselskabet Danica, Skadeforsikringsaktieselskab af 1999 CVR-nr København DK Danica Pension, Livsforsikringsaktieselskab CVR-nr København DK

Is the illness/condition/symptoms the result of an accident? If yes a: When did the accident happen? b: What happened and what was the direct cause? Time: 3. c: Has a police report been filed?

2 8. What kind of treatment are you going to receive? 9. Who is going to provide the treatment? *) Treatment with these healthcare staff requires a doctor s referral or recommendation. **) These treatment providers must be certified registered alternative therapists (Registreret Alternativ Behandler - RAB). Private hospital/clinic Specialist medical practitioner Chiropractor Physiotherapist*) Psychologist*) Acupuncturist**) Zone therapist**) Private hospital/clinic abroad Dependence treatment centre*) Dietitian*) 10. Are you a member of the health insurance company danmark? 11. Which group: Have you reported the illness/condition under another insurance or is it covered by another insurance? Which company: Policy number: Declaration I declare that all questions have been answered to the best of my knowledge and that I have not withheld any information which might be relevant to a decision on whether the conditions laid out in the insurance policy have been fulfilled. Date CPR-. Signature

Private hospital/clinic Specialist medical practitioner Chiropractor Physiotherapist*) Psychologist*) Acupuncturist**) Zone therapist**) Private hospital/clinic abroad Dependence treatment centre*)

3 CONSENT INSURANCE EVENT FP CONSENT TO OBTAINING AND PASSING ON INFORMATION Danica Pension Parallelvej 17 DK-2800 Kgs. Lyngby Denmark Telephone Why we need your consent Pursuant to the Danish Insurance Contract Act, you must provide your insurance company with all accessible and relevant information when filing a claim. Therefore, you are under an obligation to disclose to Danica Pension all the information that may affect the assessment of your claim and the size of the compensation payable to you. Claims and compensation The Act also stipulates that you are not entitled to any compensation under your insurance until two weeks after Danica Pension s receipt of your claim. The information stated in the claim is necessary for us to assess your situation and determine how much compensation you may be entitled to. Exchange of health information The Danish Health Act stipulates that, subject to your consent, your doctor may pass on information about your health, information about other personal matters and other confidential information. Other legislation also allows public authorities and insurance companies, etc. to pass on information about you on condition that you have given your consent. You may withdraw your consent at any time Your consent is in force for a year from issue. A copy of your consent will be submitted to all parties from whom Danica Pension requests information. You can always withdraw your consent if you no longer wish it to be in force. You will be notified each time Danica Pension obtains information You will be notified each time Danica Pension obtains specific information. The notice will state why we requested the information, the type of information we have requested, the precise period in which we are interested and from whom we have requested it. Consent I hereby give my consent to Danica Pension obtaining all relevant information. Such information may be information about illness, information about my health, including contacts to health services, information about social matters and the like. I consent to Danica Pension obtaining information from doctors, hospitals and other relevant health service units, public authorities, including local government, the Danish National Board of Industrial Injuries, the police and other insurance companies, pension funds and the Danish Centre of Health and Insurance. The information obtained may be passed on to other insurance companies, pension funds, the Danish National Board of Industrial Injuries and other duly authorised health personnel involved in the consideration of my proposal. This consent concerns information prior to the date on which Danica Pension has assessed my claim for compensation. A copy of this consent will be sent to any doctor, local government institution, etc. from whom Danica Pension may request information. Date CPR-. Signature The Certificate Committee of the Danish Medical Association and the Danish Insurance Association has given its approval to this consent being used for obtaining health information etc. from doctors. Supplementary information given by doctors requires a specific statement that may be supplemented with copies or extracts of relevant records at the insurer s/pension fund s request. The Danish Medical Association and the Danish Insurance Association 2008 Forsikringsselskabet Danica, Skadeforsikringsaktieselskab af 1999 CVR-no Copenhagen DK Danica Pension, Livsforsikringsaktieselskab CVR-no Copenhagen DK

4 To be completed by the insured s own doctor if he or she finds that the insured requires examination/treatment. As the insured s doctor, you must answer all the questions and state the date and your CPR./CVR. when stamping and signing the claim. 1. Who is the patient? CPR-.: 2. Which illness/disease does the patient have? How many years have you known the patient? Latin: Danish: 3. Does the patient need examination/treatment of this 4. What examination/treatment must the patient receive? If dietary treatment is required, please state 5. Have you referred the patient to specialist care or treatment? Height: Weight: 6. What is the presumed or ascertained cause of the 7. When did the illness/condition first arise? 8. When did the patient first consult you or another doctor for this 9. Has the patient previously suffered from the same illness/condition/symptoms? 10. Is there a connection between the patient s current illness/condition and a previous or other existing Which illness/condition: When did the illness/condition start:

Which illness/disease does the patient have? How many years have you known the patient? Latin: Danish: 3. Does the patient need examination/treatment of this 4.

5 11. Has the patient previously been treated for this illness/disease? Which kind of treatment did the patient receive: Who treated the patient? Please attach any discharge reports/examination results, etc. which might affect the processing of the claim. Date Doctor s signature and stamp CPR-./CVR. The insured s doctor must send this claims form to Danica Pension, Sundhedsgruppen, Parallelvej 17, DK-2800 Kgs. Lyngby.

Please attach any discharge reports/examination results, etc.

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 ( )