Beazley Energy Super Income Protection. form. claim

Transcription

1 Beazley Energy Super Income Protection form claim

2 Beazley Energy Super Income Protection Claim form Page 2 claim contents form Privacy statement Page 3 Important notice Page 4 Section A Claimants section Page 5 Section B Doctor s section Page 16 Section C Employer s section Page 20 How to complete this form Please note, no benefits are paid during the waiting period applicable to your division. Instructions: 1. Section A is to be completed by you, the claimant. 2. Section B is to be completed by your treating doctor. 3. Section C is to be completed by your employer. 4. Please forward your completed claim form to: Address: Beazley Claims Reply Paid 1196 Royal Exchange NSW 1224 (No postage stamp required) Fax: +61 (2) SydneyClaims@beazley.com 5. If you have any enquiries please contact the claims department on: Toll free: (not available from mobile phones) Phone: +61 (2)

3 Beazley Energy Super Income Protection Claim form Page 3 Privacy statement Personal information including your full name, address, contact details, age, gender as well as your health and financial information is information used to allow others to identify you. The Privacy Act 1988 requires us to inform you that as an Insurer, we may collect, store and disclose your personal and sensitive information in order to: Determine whether to issue a policy; Determine the terms and conditions of your policy; Compile data; and Handle claims We will act to protect your personal information in accordance with the National Privacy Principles (Australian Privacy Principles effective 12 March 2014) or an industry code and the protection of your personal information is a vital part of our service. We may disclose personal or sensitive information to external organisations that help us provide you a service. These organisations are bound by confidentiality agreements and they may include overseas organisations. Sensitive information includes, amongst other things, information about an individual s health, membership of professional associations and criminal records. We may disclose personal information to third parties who we deal with in providing the relevant services and products. Personal information may be communicated to, released or obtained from (but not limited to): Brokers and agents who refer business to us; Any person acting on your behalf, including your advisor, solicitor or accountant, trustee, guardian or attorney; Any past or present Employer or Union Delegate or Representative; Medical Practitioners and Allied Medical Professionals (to verify or clarify health information you provided or as part of an independent medical examination); Claims investigators and reinsurers (so that any claim you make can be assessed and managed); Insurance reference agencies; Other insurers (to verify or clarify other claims made e.g. Workers Compensation); Any Government Body or Complaint Tribunal or Ombudsman; and/or Organisations including overseas organisations, to whom we may outsource certain functions. In all circumstances where our contractors, agents and outsourced services providers become aware of personal information, confidentiality agreements apply. Personal information may only be used by our agents, contractors and outsourced service providers for our purpose. You are able to access your information held by Beazley Underwriting Pty Ltd at any time. Information including reports may be provided under the following authorities, other than in limited circumstances set out in the National Privacy Principles. Beazley Underwriting Pty Ltd aims to ensure that your personal information is accurate and up-to-date and complete. Please contact us, if you would like to seek access to, or revise your personal information or feel that the information we currently have on record is incorrect or incomplete or believe that the privacy of your personal information at Beazley Underwriting Pty Ltd has been interfered with. Your complaint will be managed and resolved through our internal dispute resolution process. We recommend that you retain a copy of this statement for your records.

4 Beazley Energy Super Income Protection Claim form Page 4 Important notice In order to alleviate any delay in the processing time of your claim, please note the following: The claim form is returned with all fields completed. Incomplete forms will be returned to obtain missing information. You have provided a certified copy of your Photo Identification (eg. Drivers Licence or Passport). It is essential that you provide us with the name and address of any Medical Practitioner(s) for whom treatment has been received within the past 5 years, as requested in Section A Claimant s Section. For employees: A wage report is to be provided from your employer detailing each weekly/fortnightly/monthly wage for the 12 months prior to the date of incapacity, to calculate the benefit applicable on your claim. Alternatively, you might be eligible to calculate benefits based on your base annual salary at the time of your incapacity. Please note this option is only available dependent on the policy period your claim is applicable to. To consider this alternative option, we require you to provide a copy of your employment contract to confirm your base annual salary or a pay slip. If you are self-employed, you must submit a copy of your individual and business Tax Returns, Notice of Assessments and Financial Statements (e.g. Profit and Loss Statement, Balance Sheet, etc) issued by the Australian Taxation Office for the last financial year prior to your incapacity. If you are suffering from a psychological condition, we require you to obtain a medical report from your treating psychiatrist/psychologist outlining your diagnosis, the date you first consulted the specialist, treatment and frequency and anticipated dates of returning to partial and full duties. Please note that medical certification can only be issued by a treating psychiatrist. All medical certificates must state the medical condition rendering you unfit for work, provide a period of certification, your capacity to work (eg. totally unfit, fit for partial duties etc), provide the anticipated return to work dates and be issued by the doctor who consulted you during the certified period. If you are providing backdated medical certificates, these must be completed by the doctor you consulted during the certified period and supported with clinical notes to enable us to consider this as valid certification. If you have had any surgical procedures, a copy of your hospital discharge summary and operational report (can be obtained from your treating doctor/general practitioner) must be provided. If you have undergone any medical scans (eg. X-rays, CT, MRI etc), please provide a copy of the accompanying report. Please be advised we do not require the original scan/film. In the event that your doctor deems that your medical condition is work related, you are required to lodge a Workers Compensation claim, prior to the consideration of any claim benefits under this policy. For any claims related to Workers Compensation, Compulsory Third Party or any other insurance providers, you are require to provide a copy of your Acceptance/Decline letter. Where liability has been accepted, please provide copies of all benefits paid. If you have lodged a claim with another income protection insurer, sports insurer, travel insurer or any other insurer (excluding Workers Compensation), please provide a copy of the policy wording. In order for us to process any payments in relation to your claim, please complete Section A of the Individual Tax File Number Declaration form (which can be obtained from selected newsagents). Please note the original copy of this form is required. If police were involved in any incident resulting in this claim, please provide a copy of the police report. Any fraud, misstatement or concealment by you in relation to any matter affecting this insurance in connection with making of any claim under it, will give us the rights provided for in the Insurance Contract Act, including where appropriate the right to reduce or refuse payment of any claim.

5 Beazley Energy Super Income Protection Claim form Page 5 Section A Claimant s section to be completed by claimant All questions must be completed and claim form signed before we can process your claim. (Please print responses clearly in BLOCK LETTERS) Part 1: Your details Title: First name(s): Middle name(s): Surname: Have you ever been known by any other name: Yes No If yes, please advise: Please provide a copy of your photo Identification and evidence of any name change. Date of birth: / / Gender: Male Female Residential address: Suburb: State: Postcode: If your postal address is the same as your residential address please state AS ABOVE Postal address: You must provide a contact number that we can contact you DIRECTLY on Phone: Mobile: What is your preferred method of written correspondence? Regular post Is English your first language? Yes No If no, what language do you speak at home? Do you require an interpreter? Yes No If yes, what language? What is your: Height: cm Weight: kg Has your weight altered by more than 10kg during the past year? Yes No Has it increased / decreased by kg Have you ever been/or currently a smoker? Yes No when was your last cigarette? How many cigarettes did you/do you smoke a day? Part 2: Your details All claims will be paid via Electronic Funds Transfer (EFT). The bank, building society or credit union account MUST be in your name. A joint account is acceptable, however any payments made to a joint bank account may be viewed and accessed by the joint party. Account numbers cannot be a card number. Please provide the following information: Bank: Account name: BSB: Account number:

6 Beazley Energy Super Income Protection Claim form Page 6 Part 3: Membership details Please call Energy Super on ENERGY ( ) if you do not know your membership details: 1. Membership number: 2. What is your membership division? a. Division 1 What is your current category level? A B C D E F G b. Division 2 How many units have you elected? c. Division 3 Part 4: Medical information SICKNESS (Please complete questions 3 to 8 if your condition is related to a sickness only) 3. What is your diagnosis? 4. When did you first consult a doctor? / / 5. Who did you consult? a. Name of doctor: b. Name of medical centre/hospital: c. Address: d. Contact number: 6. Is this your usual treating doctor? Yes No 7. What were your symptoms? 8. What date did you first experience symptoms? / / Proceed to question 16 INJURY (Please complete questions 9 to 15 if your condition is relation to an injury only) 9. Please provide the full details of the nature and extent of your injuries? 10. How did you injury occur? 11. When did your injury occur? / / am/pm 12. When did you first consult a doctor? / /

7 Beazley Energy Super Income Protection Claim form Page Who did you consult? a. Name of doctor: b. Name of medical centre/hospital: c. Address: d. Contact number: 14. Is this your usual treating doctor? Yes No 15. Did anyone witness your injury? Yes No a. Name of witness: b. Address: c. Contact number: Proceed to question When did you first cease work due to your medical condition? / / 17. Were you medically certified from this date? Yes No 18. What was the treatment recommended to you? 19. When do you anticipate you would be fit to return to work? a. Partial duties/hours: / / b. Full duties/hours: / / 20. Were you admitted to hospital as a result of your medical condition? Yes No a. Date you consulted the hospital: / / b. Date you were admitted: / / c. Hospital details: Please provide a copy of your hospital discharge summary form. 21. Are you/were you required to undergo surgery due to your current medical condition? Yes No a. When was the surgery due to be completed/undergone? / / b. What was the surgery performed? c. What is your expected recovery time? weeks

8 Beazley Energy Super Income Protection Claim form Page Are you consulting any allied health professionals (eg. psychologist, physiotherapist, chiropractor etc) for treatment? Yes No a. Date of first consultation: b. Treatment provided: c. Frequency of treatment: d. Name of allied health professional: e. Contact number: Please provide details on a separate page if you have consulted more than one allied health professional. 23. Have you suffered from this medical condition in the past? Yes No a. Date of past consultation: b. Diagnosis: c. Doctor details: d. Treatment provided: e. Did the condition fully resolve? Yes No 24. Have you returned back to work since the date advised on question 16? Yes No a. What period did you return to work? / / to / / b. What was your working capacity? (eg. working on reduced duties, full duties) 25. Are you suffering from any other medical conditions which may delay your recovery? Yes No a. If yes, please list conditions: 26. Please provide the details of your medical practitioners for the last five years: a. Doctor 1: Name: Address: Suburb: Postcode: Phone: Fax: b. Doctor 2: Name: Address: Suburb: Postcode: Phone: Fax: If you have visited more than two medical practitioners over the past five years, please provide details on a separate page.

9 Beazley Energy Super Income Protection Claim form Page 9 Part 5: Employment details 27. What is your occupation at the time of your disablement? 28. What is your job title? 29. Were you employed in a supervisory role? Yes No a. If yes, how many staff did you supervise? 30. Describe your work duties in detail, including the type of duties and percentage of time spent on each duty? 31. What percentage of your work is manual? % 32. Please confirm the physical requirements of your role (where applicable): Percentage of time spent on task (please tick) Percentage of time spent on task Task <30% 31%-70% >71% Task % per day Lifting 20kg & over Walking Lifting, 7kg 19kg Standing Lifting, under 7kg Sitting Carrying, 20kg and over Kneeling Carrying, 7kg -19kg Crawling Carrying, under 7kg Climbing ramps, steps Lifting/reaching over shoulders Climbing ladders, scaffolding 33. What qualifications, training and experience do you have? Please provide a copy of your most current resume, including your employment history and education and training. 34. Prior to your disability, what were your usual hours and days worked per week? a. Hours per week b. Usual days worked per week c. Hours of work From am/pm to am/pm 35. Were you on maternity/paternity/study/leave without pay/unpaid leave or unemployed when you became incapacitated to work? Yes No a. If yes, please provide details and reasoning: 36. Were you required to travel as part of your job? Yes No a. If yes, approximately the number of kilometers per week? km/week 37. How far is your home from your place of work? km mins/hours 38. How would you usually get to work each day? (Eg. Drive, walk, public transport etc)

10 Beazley Energy Super Income Protection Claim form Page Do you have a second occupation? Yes No a. Company name: b. Job title: c. Duties: d. Address: e. Contact number: f. Line manager: 40. Are you self employed? Yes No (If no, please proceed to question 48) SELF-EMPLOYED (Please complete questions 41 to 47 if you are self-employed only) 41. What is your business name? 42. What is your ABN or ACN? 43. What is your business structure? Sole trader Partnership Company Trust 44. What is your business address? (must be the address of the business and not a PO BOX address) 45. How long have you been self-employed? years months 46. How many employees do you have in your business? 47. Are you still receiving an income from your business since your incapacity to work? Yes No Please provide a copy of your individual and business tax returns and assessment for the financial year prior to your incapacity to work. Please proceed to question 54 EMPLOYEE (Please complete questions 48 to 53 if you are an employee only) 48. What is the nature of your employment: Fulltime Part-time Casual other 49. What date did you commence employment? / / 50. Were you employed on a contract basis? Yes No a. If yes, when is your contract expected to end? / / 51. Have you been in receipt of any payments from your employer after your date of incapacity? Yes No Period paid Type of entitlement (eg. Sick leave, annual leave) Amount paid

11 Beazley Energy Super Income Protection Claim form Page Please provide the details of your most recent employer: a. Name of employer: b. Address: c. Postal address: d. Phone: e. Fax: f. g. Direct manager name: 53. If applicable, which option would you prefer in the calculation of your benefits: Using 12 months of wages immediately prior to your incapacity,or Using your annual base salary. It is important to remember that your annual base salary will not include any allowances or monies earned during overtime. Please note that this option is not available on all claims and is dependent on the the policy terms and conditions applied to your claim. Please proceed to question 54 Part 6: Other insurance 54. Did your medical condition occur as a result of work? Yes No Please note that you are required to lodge a Workers Compensation claim prior to the consideration of any claim benefits under this policy. a. Have you or are you intending to lodged a Workers Compensation claim? Yes No b. What is your Workers Compensation claim number? c. Insurer: d. Contact number: e. Claims officer: 55. Was your medical condition a result of a motor vehicle or motorbike accident? Yes No a. Were police involved? Yes No b. Are there any charges being investigated or laid by the police? Yes No c. Incident number: d. CTP claim details: Insurer: Claim number: Contact number: Claims officer:

12 Beazley Energy Super Income Protection Claim form Page Was your medical condition a result of playing sports? Yes No a. If yes, were you playing sports at a club level (competition) or recreational? Club level Recreational 57. Have you or are you intending to lodge any other type of insurance claim? Yes No a. Claim number: b. Insurer: c. Type of cover: d. Contact number: e. Claims officer: Check list 1. I have read the privacy statement included on page 3 of this form Yes 2. I have attached a verified copy of my photo identification (ie. Drivers licence, passport) Yes 3. I have attached evidence of my name change Yes n/a 4. I am suffering from a psychological condition and have attached the letter from my psychologist/psychiatrist Yes n/a 5. I have provided a copy of my hospital discharge form Yes n/a 6. I have provided a copy of my resume Yes 7. I am self-employed and have provided a copy of my individual and business tax returns Yes n/a 8. I am an employee and have provided a copy of my wage information (eg. base salary and/or 12 month wage report) Yes n/a 9. My medical condition is work related and I have lodged a claim with the Workers Compensation insurer Yes n/a 10. I have completed and I have attached the original tax file number declaration form Yes 11. I have signed the Authority and consent declaration on page 15 Yes 12. I have completed the authority form on page 13 to discuss my claim with a third party Yes n/a 13. I have completed the authority on page 14 to allow Beazley to discuss my claim with my employer in the event I am capable of returning to work in a partial capacity Yes n/a

13 Beazley Energy Super Income Protection Claim form Page 13 Third party authority (optional complete only if required) To assist with the claims process, you may want to authorise a family member or friend to act on your behalf of this claim. If so, please complete the below authority. To be completed by the claimant I acknowledge that the information provided to the person listed below may include any information that Beazley Underwriting Pty Ltd holds about me in respect of my claim. This may include, health, lifestyle, employment, financial, medical and insurance information. I hereby authorise the person listed below to receive this information on my behalf on my claim. They have been made aware and have consented to their personal details listed below, to be given to Beazley Underwriting Pty Ltd. I hereby confirm that if in future, I no longer require the person mentioned below to act as a third party, I will notify Beazley Underwriting Pty Ltd, immediately in writing. Title: First name(s): Surname: Residential address: Suburb: State: Postcode: Phone: Mobile: Date of birth: / / Relationship to claimant: Signature of claimant: Name of claimant: Date: / /

14 Beazley Energy Super Income Protection Claim form Page 14 Authority to release information to any employer (optional complete only if required) In order to assist with the assessment and ongoing management of your claim, we maybe required to engage/liaise with your employer (rehabilitation/return to work team). To enable Beazley to do this we would require your authority. To be completed by the claimant I (name of claimant), / / (date of birth) of (Address), hereby give permission for Beazley to discuss and exchange details of my injury and/or illness, currently diagnosed as with the appropriate rehabilitation and return to work team at I also give permission for the following medical practitioner(s) or allied health provider(s) to assist with my rehabilitation or return to work, to disclose information relevant to my current injury or illness. Name Profession Address Phone Fax Additional: I give permission for Beazley to release relevant medical information in respect of my claim including information obtained from any doctor(s), hospital(s) and health professional or health institution to assist in my ongoing rehabilitation or return to work. Yes No I acknowledge that Beazley will regularly consult with my medical practitioner(s) or allied health provider(s) and employer(s) to obtain updates with the progress of my rehabilitation and return to work. I understand that the information obtained and discussed from this consent will be used to assist in my rehabilitation and return to work with respect to my current injury and/or illness as stated above. I understand that the privacy and confidentiality of all information collected will be respected. My personal information will only be given to another person or body without my consent where authorized or required by law. I declare that the information provided on this form is complete and correct and that giving false or misleading information is a serious offence. Signature: Name: Date: / /

15 Beazley Energy Super Income Protection Claim form Page 15 Authority and consent declaration I declare that I am the person named on this form or I have power of attorney to act on the claimant s behalf. I declare that the information provided in this form, to the best of my knowledge and beliefs are true and correct and if any answers to the questions completed in this form are not in my handwriting, I have certified that I have checked them and they are also correct. I understand that if I have made or make any false, misleading or fraudulent statements, conceal or intentionally withhold relevant information for the assessment or ongoing review of this claim, Beazley Underwriting Pty Ltd may: Refuse to pay this claim; and/or Recover benefits paid that were based on false or misleading information I provided; and/or Be obliged to refer such case to relevant Authority. I declare and authorise that I have read and understood the Privacy Statement provided with this form and I understand that my personal and sensitive information, may be disclosed to other parties as advised below and approve these purposes. I hereby authorise and direct any medical attendant, doctor, hospital or other medical or health service provider to divulge to Beazley Underwriting Pty Ltd, its representatives or any legal tribunal, and to release at any time details of my personal medical history, including referrals to or treatment by any other practitioners, any health or other information acquired with regard to myself for the purposes of allowing Beazley Underwriting Pty Ltd to assess and manage my claim or assess any new, additional insurances (including re-instatements). I also authorise my current and any previous employer to release to Beazley Underwriting Pty Ltd any personal or health information requested to facilitate an assessment of my claim. Under the Government Privacy Legislation, I may access a copy of any reports provided to Beazley Underwriting Pty Ltd. I authorise Beazley Underwriting Pty Ltd to obtain from Medicare such portion of my claims history deemed necessary by Beazley Underwriting Pty Ltd to properly assess and manage my claim. I also authorise the Institutions listed below to provide to Beazley Underwriting Pty Ltd any health and other personal information that Beazley Underwriting Pty Ltd considers essential and/or reasonable to further assess or evaluate my claim. I further authorise Beazley Underwriting Pty Ltd to contact, release and obtain information it requires to assess my claim for benefits, from those other sources it considers necessary including, but not limited to the following: Any doctor, ambulance, hospital or other health service provider; My employer, previous employer/s accountant/s and/or financial advisers and/or union delegate or representative; Medicare, the Insurance Commission including PBS records; Any Insurance Company, including Workers Compensation Insurer; Insurance or financial reference agencies, re-insurers, financial institutions including banks, credit unions, building societies, mortgage providers, finance companies, (and claims investigators) private investigators and detectives and forensic accountants; Government Agencies, including but not limited to Centrelink, Australian Taxation Office, Australian Securities and Investments Commission, Department of Veterans Affairs and Department of Immigration and Citizenship; Any Federal, State or Territory Police Department; Traffic Accident Commission (Victoria), State and Territory Roads and Traffic Authorities, Queensland Transport, Vic Roads Registration and Licensing Office, Transport South Australia; and/or Any other institutions that holds my personal information. I understand that Beazley Underwriting Pty Ltd may be required to submit all documentation to a mediator, solicitor, complaints resolution tribunal or court or to any other person necessary for claims determination purposes including the Trustee of any Superannuation Plan. I understand a determination of my claim may not be possible if I withhold consent and authority for Beazley Underwriting Pty Ltd to seek personal and/or health information in relation to my claim. I agree that a scanned, photocopied or faxed copy of this authority shall be considered as effective and valid as the original. Full name: Date of birth: / / Signature: Date: / /

16 Beazley Energy Super Income Protection Claim form Page 16 Section B Doctor s section to be completed by the Doctor This section is to be completed by the regular treating doctor that has been consulted for the claimed condition. Please note that any costs associated with the completion of this form are the patient s responsibility. (Please print responses clearly in BLOCK LETTERS.) Patient s details Title: First name(s): Surname: Address: Suburb: State: Postcode: Age: Date of birth: / / Height: cm Weight: kg 1. Is the patient s condition related to a: Sickness Injury 2. Date of onset of condition: / / 3. Date first diagnosed: / / 4. Date you were first consulted: / / 5. Please list all consultation dates in relation to the patient s condition (Please provide a copy of the clinical notes related to this condition): 1. / / 2. / / 3. / / 4. / / 5. / / 6. / / 7. / / 8. / / 6. How long have you been consulting the patient? years months 7. What is the patient s diagnosis? 8. What were the symptoms outlined by the patient? 9. What caused the current condition? 10. What treatment has the patient been prescribed to date? 11. Has the patient undergone any investigations? Yes No Please provide copies of all scan results and investigations. 12. Was the patient consulted or been referred for a specialist for further review? Yes No a. Date referred: b. Name of doctor: c. Specialty: d. Address: e. Contact number: f. Fax number:

17 Beazley Energy Super Income Protection Claim form Page Was the patient admitted to hospital as a result of the medical condition? Yes No a. Date admitted: / / b. Hospital details: 14. Is the patient required to undergo surgery due to their current medical condition? Yes No a. When was the surgery due to be completed/undergone? / / b. What was the surgery performed? c. What is the patient s expected recovery time? weeks Please provide copies of any hospital records and/or operation reports. 15. Was the patient recommended to obtain treatment from any allied health professionals? Yes No a. Name of allied health professional: b. Specialty: c. Address: d. Contact number: e. Fax number: 16. Was the patient offered medication for the treatment of their condition? Yes No a. Please state all medications and the date prescribed: Date prescribed Medication and dose Date ceased / / / / 17. In your medical opinion has the patient been complying with the medical treatment recommended to him or her? Yes No a. If not, please provide reasoning: 18. What is your prognosis of this condition? 19. What is the patient s occupation as described by them? 20. Are you familiar with the patient s duties and tasks? Yes No 21. Have you discussed recovery time frames with the patient? Yes No 22. When do you anticipate that the patient will be fit to return to partial duties? / / 23. When do you anticipate that the patient will be fit to return to work in their normal capacity? / /

18 Beazley Energy Super Income Protection Claim form Page Are there any factors that may affect or delay the condition and recovery? Yes No a. If yes, please provide details: 25. Has the patient ever suffered from the same/similar or related condition before? Yes No a. Did you treat the patient for the previous conditions? Yes No b. What was the condition? c. When did the patient suffer this condition previously? / / d. What was the treatment prescribed? e. Did the condition fully resolve? Yes No f. If not, please provide reasoning: 26. In your medical opinion, do you believe the condition is work related? Yes No a. Please provide your reasoning: 27. In respect of the patient s medical condition, have you issued or completed any other medical certificates or paperwork for another insurance company? Yes No a. Name of insurer: b. Type of cover: Check list 1. I have provided a copy of the clinical notes related to this condition Yes 2. I have provided a copy of the investigation scans/reports related to this condition Yes n/a 3. I have provided a copy of the hospital reports/operation reports Yes n/a 4. I have completed the doctors authority and included a period of certification on page 19 Yes

19 Beazley Energy Super Income Protection Claim form Page 19 Doctor s authority I, Doctor certify that the information provided in Section B of this form has been completed by me in full. I certify that (patients name) who is suffering from (medical condition) to be: Totally unfit for his/her usual duties: From: / / To: / / (inclusive) Fit for suitable duties: From: / / To: / / (inclusive) Restrictions: Bending/twisting/squatting Lifting up to kg Standing up to hours Sitting up to hours Pushing/pulling up to kg Driving up to hours Climbing Other (please specify) Fit for full duties from: / / Signed: Date: / / Qualifications: Address: Suburb: State: Postcode: Phone: Fax: Important notice: Please note that all certification is valid for a maximum of 8 weeks from the date it is issued. Where backdated certification is being provided, please provide copies of all clinical notes to support regular consultations. During the life of a claim, if a medical certificate is issued and supplied to Beazley by the patient, the medical condition, period of certification, capacity to work and return to work time frames must be advised in order to be valid under their insurance claim with us.

20 Beazley Energy Super Income Protection Claim form Page 20 Section C Employer s section to be completed by your Employer This section is to be completed by the employer at the time of disablement or the last known employer prior to the disablement. (Please print responses clearly in BLOCK LETTERS.) Employee details Employee name: Date of birth: / / Employee address: Employee number: Date employment commenced: / / DIVISION 3 MEMBERS ONLY: a. Date the employee s Total Accrued Sick Leave (TASL) expires on: / / b. List the number of days for the TASL: Part 1: Employment details 1. Onset of injury or sickness: / / 2. Date last physically worked due to their medical condition: / / 3. What is the medical condition and where and how did the incapacity occur? (if known) 4. Prior to the date the employee ceased working due to their disablement were they performing their full duties and hours? Yes No If no: a. Was the employee on restricted duties and/or hours? Yes No b. Was the employee on restricted duties due to the same medical condition? Yes No c. If no, please provide details for the reason the employee was on restricted duties: 5. Employee type: Full-time Part-time Casual Contractor 6. Is the employee hired for a contract/specified period? Yes No a. If yes, what date was/is the contract/specified period expected to cease? / / 7. Work status: Employed Terminated Resigned 8. If the employee is no longer employed, what date did their employment cease? / / Please provide a copy of the Employment Separation Certificate and/or resignation letter. 9. Did the employee complete any incident reports in relation to this condition? Yes No If yes, please provide a copy of the incident report. 10. In respect of this condition, has your company completed any forms for any other insurance companies? Yes No a. Name of Insurer: b. Type of cover (if known):

21 Beazley Energy Super Income Protection Claim form Page 21 Part 2: Job description 13. Employee job title: Please provide a list of duties, including the percentage of time spent in each duty and attach a copy of the role description. 14. Percentage of manual work: % 15. If the employee is capable of returning to work on alternate/restricted duties are you prepared to provide these? Yes No 16. Prior to the employee s disablement, what was their usual hours and days of work? a. Hours per week b. Days worked per week c. Hours of work From am/pm to am/pm 17. Was the employee required to travel as part of their job? Yes No a. If yes, approximately the number of kilometers per week? km/week Part 3: Wages Please provide a copy of the wage report showing a weekly/fortnightly/monthly breakdown for the 12 months immediately preceding the date of disablement. 18. What is the employee s average weekly gross? $ 19. What is the employee s annual base salary? $ (Please note this amount is purely the agreed annual salary not including overtime, bonus etc) 20. Since the date of incapacity, has the employee received any further benefits? Yes No a. Normal pay: $ Paid from / / to / / b. Sick pay: $ Paid from / / to / / c. Workers Compensation: $ Paid from / / to / / d. Other: $ Paid from / / to / / Where a benefit has been paid, please provide copies of all payslips from the date of disability to the specified period. Part 4: Workers Compensation information Please note that this information is required even if the claim is not considered by the employer to be work related. 21. What is the name of your current Workers Compensation insurer? 22. Policy number: 23. Are you a self insured for Workers Compensation? Yes No

22 Beazley Energy Super Income Protection Claim form Page Is the employee s condition work related? Yes No 25. Is the employee currently in receipt of Workers Compensation benefits? Yes No a. If no, please provide reasoning: 26. Has the employee had any previous Workers Compensation claims? Yes No a. If yes, please provide details (eg. claim number, period of Workers Compensation, medical condition) Company representative s details Signature: Title: First name(s): Last name: Position: Company name: Address: Suburb: State: Postcode: Phone: Fax: Mobile: Date: / / Check list 1. I have provided a copy of the employee s Employment Separation Certificate and/or their resignation letter. Yes n/a 2. I have provided a copy of the employee s incident report. Yes n/a 3. I have provided a copy of the employee s duties and tasks and a copy of their job description. Yes 4. I have provided a copy of the employee s 12 month wage report prior to their incapacity. Yes 5. I have provided a copy of the employee s payslips to confirm the income received after the waiting period. Yes n/a