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

Transcription

1 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 us do this and make sure our assessment is accurate. Please complete all sections of the form as requested an incomplete form could delay the assessment of your claim. This form should be completed by the parent / legal guardian of the insured child. You can nominate someone else for us to deal with during the claim process, but the policy owner will need to sign the relevant documentation. Please complete all sections as requested. Pages 5 6 provide additional space if you run out of room answering these questions, or need to provide any information not covered by the questions. We encourage you to attach supporting medical records or any other information you have that will help us in assessing your claim. We re happy to help if you have any queries about this form. Please call us on , or talk to your adviser. A. Child s details Policy number(s) Please tick one Miss Master Other Please specify Surname Residential address Given names Date of birth B. Who is completing this form Please tick one Mr Mrs Miss Ms Other Please specify Surname Given names Relationship to insured child Home phone number Work phone number Mobile phone number address Residential address (if different from child) Postal address (if different from residential) 1 of 10 Kids Claim Form Website

2 C. Authorised contact person (if different from above) Please tick one Mr Mrs Miss Ms Other Please specify Surname Given names Relationship to insured child Home phone number Work phone number Mobile phone number address Residential address Postal address (if different from residential) D. Claim details 1. What condition are you claiming for? (Please refer to your Policy Document for a full list of conditions covered) 2. a. If a sickness, when were the first symptoms noticed? b. Please describe these symptoms. 3. If an injury, when, where and how did it happen? 4. Has your child ever suffered from this condition or related condition(s) before?... Yes No If yes please provide all dates and details. Dates Specific Details 2 of 10 Kids Claim Form

3 5. Has your child consulted any doctors/specialists with regard to these previous conditions?... Yes No If yes please provide details. Name Address and phone number E. Medical details 6. a. Please provide the date of the first consultation for your child s current condition and the result. b. Please name the doctor(s)/specialist(s) your child consulted and provide contact details. 7. Please give dates of all investigations and treatments including medication, provided by your child s attending doctors for this condition. Dates Treatment Doctor Feedback, comments and suggestions If there is anything more we can do to assist you during this time, please let us know in this section. 3 of 10 Kids Claim Form

4 Privacy Act 1993 This information is being collected and will be held by Asteron Life Limited ( Asteron Life ). It is intended for use by Asteron Life employees who require access to this information for administering your claim and policy. Under the Privacy Act 1993 you are entitled to request access to and request correction of any personal information about your child held by Asteron Life Limited. If you do not supply the information sought your claim may be declined. In assessing and managing your claim we may need to disclose your child s personal information to other parties such as claims assessors, loss assessors, reinsurers, medical and financial professionals, judicial or dispute resolution bodies and Suncorp companies. Consent and Declaration I have read and understood and have made the other people named on this form aware of the privacy disclosure statement above. I acknowledge that where information is provided with the consent of the individual to whom it relates I confirm that I have the authority to act on behalf of the persons named on this form. I hereby declare that the information in this Claim Form is true, correct and complete. I understand and agree that if I make any false or fraudulent statements or fail to advise Asteron Life Limited of any relevant information regarding my claim, Asteron Life Limited may refuse to pay and cancel my claim. I understand that I can be prosecuted if I make any fraudulent statements. I hereby declare that I am the parent/legal guardian of, a minor, and am duly authorised to act on their behalf. Medical and Information Authority I hereby authorise any dentist, hospital, doctor or other person who has attended my child, to release to Asteron Life Limited or its representatives, all information with respect to any sickness or injury, medical history, consultations, prescriptions, or treatment and copies of all hospital or medical records. I agree that a photocopy (or similar copy) of this authorisation shall be as effective and valid as the original. I hereby authorise any insurer, adviser/broker, accountant, institution, employer, business entity, medical institution, professional board or company, legal professional or entity, to release to Asteron Life Limited or its representatives, all information which Asteron Life Limited requests for the purpose of assessing or investigating my claim. I agree that a photocopy (or similar copy) of this authorisation shall be as effective and valid as the original. Policy Owner(s) 1 Full name Signature Sign here Date Policy Owner(s) 2 Full name Signature Sign here Date Witness Full name Signature Sign here Date 4 of 10 Kids Claim Form Asteron Life Level 13 Asteron Centre, 55 Featherston Street, PO Box 894, Wellington 6140, NZ Ph: (Contact Centre hours: Mon Fri 8am 6pm) Fax: claims@asteronlife.co.nz Web: asteronlife.co.nz Issuer: Asteron Life Limited

5 Additional Information 5 of 10 Kids Claim Form

6 6 of 10 Kids Claim Form

7 Kids Claim Form Treating Doctor Form To be completed by your child s attending doctor. Thank you for taking the time to complete this form. We value your feedback as the treating doctor/specialist and we ask that you complete this form. We understand this form may take some time initially but in the long term will reduce the amount of queries to yourself and your patient. This will allow for a speedier assessment of the claim. Regards, Asteron Life Claims Team Freephone Number: A. Patient details Insured child s full name Date of birth 1. Are you the insured child s usual doctor?... Yes No 2. Are you the treating GP/specialist?... Yes No If specialist, what is your specialty? 3. Is the condition a: Please tick one sickness injury B. Symptoms present complaints 4. a. If sickness, when did symptoms first appear? b. Please describe these symptoms below. 5. If injury, when did the incident occur? 6. Was the injury as a result of an accident?...yes No If yes please provide details as known by you. 7 of 10 Kids Claim Form

8 C. Medical history 7. Date the insured was first ever seen by you? 8. Date the insured was first seen for the current condition? 9. Has the insured had the same or similar condition previously?... Yes No If yes please provide the dates and details. 10. What is the insured s past general medical history (if known)? D. Diagnosis 11. What is the current diagnosis and date of diagnosis? 12. How did you arrive at your diagnosis? E. Investigation associated clinical events Important: Please attach relevant results that have supported your diagnosis. 13. What investigations (if any) have been conducted? Dates Description Result 8 of 10 Kids Claim Form

9 14. Has the insured been hospitalised?... Yes No Name of hospital Procedure Date from: Date to: F. Treatment plan 15. Please explain the treatment you have recommended/provided. 16. Please explain treatment by others you have referred the insured to. 17. Do you know if the insured is having any treatment other than the above? (e.g. traditional Chinese medicine) 18. What is the prognosis? G. Referral to other specialists 19. To your knowledge, has the insured consulted anyone other than you about this condition? Dates Practitioner Contact details 20. Is there anything else you consider relevant or that we may need to know about this case? 9 of 10 Kids Claim Form

10 Important Note When returning this form, please send copies of the following: All consultation notes regarding the current condition including when symptoms were first noticed Your original referral to the specialist if applicable All specialist reports on file All test results including histology, scan and blood test results Any hospital notes on file e.g. hospital discharge summaries I hereby declare that the above statements are true and correct. Full name Signature Date Sign here Doctors stamp Phone number Fax number Address Qualification Treating specialist: Yes No 10 of 10 Kids Claim Form Asteron Life Level 13 Asteron Centre, 55 Featherston Street, PO Box 894, Wellington 6140, NZ Ph: (Contact Centre hours: Mon Fri 8am 6pm) Fax: claims@asteronlife.co.nz Web: asteronlife.co.nz Issuer: Asteron Life Limited