GROUP PERMANENT HEALTH INSURANCE

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1 GROUP PERMANENT HEALTH INSURANCE Claim form Note: Please answer all questions carefully. Failure to provide full information may delay claim consideration. Scheme Name University of Limerick PERSONAL DETAILS Please specify Mr Mrs Ms Other Forename: Surname: Date of birth: Address: address: Contact phone numbers: (home) (mobile) PPS number: PRSI class: Civil Status: Married Single Widow(er) Separated Divorced Civil Partner Former Civil Partner Occupation: Please describe in full detail the exact nature of your occupation: 1

2 MEDICAL DETAILS Please state the exact nature of the incapacity from which you are suffering: In what way does this incapacity prevent you from following your occupation? Which duties can you still perform? Please give the date on which symptoms first commenced: When did the incapacity cause you to cease working? (If on annual leave when commenced sick leave, please only note the date you commenced sick leave.) When do you expect you will be fit to return to work? Please give details of any previous period of disability due to this or any other cause: Name and address of your usual Medical Attendant: Have you consulted him/her in respect of your present incapacity? If yes please supply: Date of first attendance: Yes No Date of most recent attendance: 2

3 MEDICAL DETAILS (continued) Have you consulted any other doctors or attended hospital as an in-patient or as an out-patient in relation to your current incapacity? If yes, please supply their names and addresses: Yes No If yes, please supply date of first and most recent attendance: Date of first attendance: Date of most recent attendance: What treatment are you currently receiving? Who prescribed this treatment? 3

4 FINANCIAL DETAILS Please state your salary or gross earnings over the 12 months immediately prior to commencement of your disability: How much of your gross earnings have you lost as a result of your disability? Are you entitled to sick pay? Yes No If yes, how much and when does it cease? Does any other part of your earnings continue during disability? Yes No If yes to any of the above please give details: Are you claiming or entitled to claim sickness or accident benefit from any of the following: Another Insurance Company? Retirement Benefit? State Disability Benefit? Any other source? If yes to any of the above please give details: While absent from work, have you engaged in any other occupation, either on a full or part-time basis? Yes No If yes, please give full details: OTHER INFORMATION Please give any other information which may be of assistance in assessing this claim: 4

5 DECLARATION I declare that the above statements are true and complete and that I am the person referred to in the particulars given. I consent to Zurich Life Assurance plc ( Zurich Life ) seeking information from any doctor who has attended me or subsequently attends me, or any hospital in which I have received or subsequently receive treatment, and I authorise the giving of such information. I also authorise the release, to Zurich Life, of any other information, which Zurich Life considers relevant to enable my claim to be dealt with. DATA SHARING CONSENT Zurich Life is a member of Zurich Insurance Group ( the Group ). In order to provide a seamless insurance service globally, Zurich Life may transfer any data it has received from, and any data it holds on me to other units of the Group, such as branches, subsidiaries, or affiliates within the Group, cooperative partners of the Group, coinsurance and reinsurance companies located in this country or abroad. Zurich Life, as well as such recipients may use, process and store the data, in particular for the purpose of risk evaluation, policy execution, premium setting, premium collection, claims assessment, claims processing, claims payment, statistical evaluation or to otherwise ensure the Group global insurance service delivery. If a financial advisor or agent is acting on my behalf, Zurich Life is authorised to use, process and store data received from such financial advisor or agent, and to forward to such financial advisor or agent my data relating to the execution of the policy, collection of premiums and payment of claims. Zurich Life may procure data from third parties including private investigators to assess a claim. Zurich Life may check my personal data against international/economic or financial sanctions, laws or regulated listings. You have a right of access to and the right to rectify the data concerning you held by Zurich Life/the Group. Signature X Date 5

6 Willis Grand Mill Quay, Barrow Street, Dublin 4, Ireland. Telephone: Fax: Website: Willis Risk Services (Ireland) Limited (t/a Willis) is regulated by the Central Bank of Ireland. Intended for distribution within the Republic of Ireland. Zurich Life Assurance plc Zurich House, Frascati Road, Blackrock, Co. Dublin, Ireland. Telephone: Fax: Website: Zurich Life Assurance plc is regulated by the Central Bank of Ireland. Print Ref: ZURL LP (Willis) 6

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