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

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "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: 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: Web: asteronlife.co.nz Issuer: Asteron Life Limited

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

Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140

Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140 Accident Insurance Claim Form Please print out for signatures and post original to AIG, PO Box 1745, Shortland Street, Auckland 1140 Employer /Group / Bank group: Full policy Number with Prefix : Full

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

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

Journey Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A.

Journey Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A. INSURANCE SOLUTIONS CLAIM FORM Journey Injury EXTF052 Call ATC Claims for assistance on 1800 994 694 1. You complete Section A. 2. Your Medical Practitioner completes Section B. 3. Your Employer completes

More information

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

INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM

INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM 1 of 7 INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement The claimant is to complete all

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

Make an AXA Total and Permanent Disability Claim

Make an AXA Total and Permanent Disability Claim Make an AXA tal and Permanent Disability Claim Thank you for contacting Swann Insurance You must have access to a printer in order to access this form. If you do not have access to a printer, please contact

More information

Sports Injury CLAIM FORM. Call ATC for assistance on 1800 994 694. 1. You complete Section A and B.

Sports Injury CLAIM FORM. Call ATC for assistance on 1800 994 694. 1. You complete Section A and B. INSURANCE SOLUTIONS CLAIM FORM Sports Injury EXTF03520130320 Call ATC for assistance on 1800 994 694 1. You complete Section A and B. 2. If you have a Non Medicare Expense claim, you should also complete

More information

AMWU PROTECT INJURY AND SICKNESS

AMWU PROTECT INJURY AND SICKNESS INSURANCE SOLUTIONS CLAIM FORM AMWU Protect Injury EXTF061 For dental claims, please use the AMWU Protect Accidental Dental Injury claim form. Call ATC for assistance on 1800 994 694 1. You complete Section

More information

Sports Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A and B.

Sports Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A and B. INSURANCE SOLUTIONS CLAIM FORM Sports Injury EXTF04820140311 Call ATC Claims for assistance on 1800 994 694 1. You complete Section A and B. 2. If you have a Non Medicare Expense claim, you should also

More information

Contractors Injury and Sickness

Contractors Injury and Sickness INSURANCE SOLUTIONS CLAIM FORM Contractors Injury and Sickness EXTF059 Call ATC Claims for assistance on 1800 994 694 1. You complete Section A, including either the Injury statement OR the Sickness statement.

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Underwriting Australia Sports Underwriting Australia Claims Department PO E: liabilityclaims@sportsunderwriting.com.au Box 2717, Taren Point. NSW, 2229 Tel: Ph: 1300 363 363 413 413 Fax: +61 2 9524

More information

PERSONAL ACCIDENT BENEFITS CLAIM FORM

PERSONAL ACCIDENT BENEFITS CLAIM FORM PERSONAL ACCIDENT BENEFITS CLAIM FORM Please note that we have to ensure that our claim form covers all types of claims. If you do not consider a question to be relevant to your circumstances please enter

More information

Combined Insurance Claim Form

Combined Insurance Claim Form Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.

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

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

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

UPlus Income Protection Claim Form

UPlus Income Protection Claim Form UPlus Income Protection Claim Form Frequently Asked Questions How long will it take to complete my section of the form? We ve tested it -- it takes about 20 minutes. We want to settle your claim for you

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

Accident Claim form (W)

Accident Claim form (W) Accident Claim form (W) Policy no Claim no Full name Customer Account Number Combined Insurance seeks to pay all genuine claims. We check all claims carefully to identify fraudulent or exaggerated claims.

More information

Construct Australia Income Protection Services Injury and Sickness Claim Form

Construct Australia Income Protection Services Injury and Sickness Claim Form 1 of 6 Construct Australia Income Protection Services Injury and Sickness Claim Form This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement Section

More information

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE You fully complete every question before your doctor completes his statement.

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

Claim lodgement process for Loss of Income Protection Group Insurance

Claim lodgement process for Loss of Income Protection Group Insurance Claim lodgement process for Loss of Income Protection Group Insurance We hope this flowchart will help you better understand how making a claim works and what we jointly need to do to have the claim assessed

More information

Protect Injury and Sickness

Protect Injury and Sickness INSURANCE SOLUTIONS CLAIM FORM Protect Injury and Sickness EXTF058 For dental claims, please use the Protect Accidental Dental Injury claim form. Call ATC for assistance on 1800 994 694 1. You complete

More information

Accident And/Or Sickness Claim Form

Accident And/Or Sickness Claim Form Accident And/Or Sickness Claim Form Please forward this completed form to: Claims Department JUA Underwriting Agency Pty Ltd Locked Bag 11 ROYAL EXCHANGE POST OFFICE NSW 1225 Policy underwritten by certain

More information

Macquarie Life Total Permanent Disability (TPD): Claimant s Statement

Macquarie Life Total Permanent Disability (TPD): Claimant s Statement Macquarie Life Total Permanent Disability (TPD): Claimant s ment Filling in this statement Please complete all sections, use black ink and mark boxes like this with an X. 1 May we disclose information

More information

Community Underwriting Personal Accident Claim Form

Community Underwriting Personal Accident Claim Form Community Underwriting Personal Accident Claim Form About the Insurer Calliden Insurance Limited (us/we/our) (Calliden) (ABN 47 004 125 268, AFSL 234438) is the insurer and issuer of this Policy and this

More information

GIO Workers Compensation Australian Capital Territory

GIO Workers Compensation Australian Capital Territory GIO Workers Compensation Australian Capital Territory Employer s report of injury claim form Employer cost centre GIO reference number Injury Register Report only to insurer Early injury management request

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

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Injury Claim Form Sports Underwriting Australia Claims Department PO Box 2717, Taren Point. NSW, 2229 Tel: 1300 363 413 Fax: 02 9524 9003 Email: sua@au.innovation-group.com Members Name: Address:

More information

SPORTS PERSONAL ACCIDENT AND SICKNESS CLAIM FORM

SPORTS PERSONAL ACCIDENT AND SICKNESS CLAIM FORM SPORTS PERSONAL ACCIDENT AND SICKNESS CLAIM FORM THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY Please Ensure: You fully complete every question before your doctor completes his statement. Failure

More information

Terminal Illness benefit applications with OnePath Life Limited Information guide

Terminal Illness benefit applications with OnePath Life Limited Information guide Terminal Illness benefit applications with OnePath Life Limited Information guide Group Risk Insurance Claims Phone 1800 648 921 Fax 02 9234 8970 Email group.claims@onepath.com.au Website onepath.com.au

More information

STUDENT ACCIDENT INSURANCE CLAIM FORM FEDERATION OF PARENTS & CITIZENS ASSOCIATIONS OF NEW SOUTH WALES

STUDENT ACCIDENT INSURANCE CLAIM FORM FEDERATION OF PARENTS & CITIZENS ASSOCIATIONS OF NEW SOUTH WALES STUDENT ACCIDENT INSURANCE CLAIM FORM FEDERATION OF PARENTS & CITIZENS ASSOCIATIONS OF NEW SOUTH WALES The issue or acceptance of this form is not construed as an admission of liability on the part of

More information

AIG no longer issues cheques. To confirm transfer of funds, an auto email will be sent to your broker or direct Email: Broker/Payee

AIG no longer issues cheques. To confirm transfer of funds, an auto email will be sent to your broker or direct Email: Broker/Payee Personal Accident or Sickness Scheme (Individual or Group) Claim Form Please print out for signatures and post original to your broker if applicable or direct to AIG, PO Box 1745, Shortland Auckland, 1140

More information

Claim Number. Departure Date: From / / To / / Occupation Date of Birth / / Date of Booking Travel Arrangements Date of Departure Date of Return

Claim Number. Departure Date: From / / To / / Occupation Date of Birth / / Date of Booking Travel Arrangements Date of Departure Date of Return Savannah Insurance Agency Pty Ltd ABN 84 130 364 313 Corporate Travel Claim Form Details of the Insured Insured Name (Traveller) Policy Number Claim Number IMPORTANT 1. Please complete the Policy Details

More information

Personal Accident Claim Form

Personal Accident Claim Form Personal Accident Claim Form Claimant Details Title Full Name Date of Birth Occupation Usual Country of Domicile Claimant Address: Contact Details Postcode: Daytime Telephone: Email Address: Wherever possible

More information

Thank you for contacting CGU Insurance

Thank you for contacting CGU Insurance Make a Trauma Claim Thank you for contacting CGU Insurance You must have access to a printer in order to access this form. If you do not have access to a printer please contact our office on 1800 248 224

More information

Claim form. Overseas Officers Insurance Policy. Accidental Death and Capital Benefits and Compassionate Travel YOUR DETAILS

Claim form. Overseas Officers Insurance Policy. Accidental Death and Capital Benefits and Compassionate Travel YOUR DETAILS Claim form Overseas Officers Insurance Policy Accidental Death and Capital Benefits and Compassionate Travel M U T U A L B R O K E R S P T Y L T D Arranged by Mutual Brokers ABN 73 008 602 266 AFSL Number

More information

CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES

CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES CLAIM FORM FOR LOSS OF INCOME &/OR RE-IMBURSEMENT OF MEDICAL EXPENSES UNDER UNIVERSITY OR SPORTING ASSOCIATION POLICIES Correct completion of these forms will assist us to make accurate and faster decisions

More information

' Home Phone. ' Work Phone. ' Mobile / / Policy Number Date Issued Number in Party. Date of Booking Departure Date Return Date Total Days

' Home Phone. ' Work Phone. ' Mobile / / Policy Number Date Issued Number in Party. Date of Booking Departure Date Return Date Total Days You must register any claim within 30 days after completion of your travel. You need to supply to us original documents of the evidence you intend to rely upon in your claim, by registered post to ensure

More information

PayCover Income Protection Claim Form

PayCover Income Protection Claim Form PayCover Income Protection Claim Form Frequently Asked Questions How long will it take to complete my section of the form? We ve tested it -- it takes about 20 minutes. We want to settle your claim for

More information

PERSONAL INJURY INSURANCE CLAIM FORM. Basketball SA

PERSONAL INJURY INSURANCE CLAIM FORM. Basketball SA PERSONAL INJURY INSURANCE CLAIM FORM Basketball SA SPORTS PERSONAL ACCIDENT CLAIM FORM Dear Soccer NSW Futsal Member 1 Dear Basketball member, Please find attached a claim form. Before lodging this form,

More information

Travel Insurance Claim Form

Travel Insurance Claim Form Jetstar Travel Travel Insurance Insurance Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for

More information

Private medical insurance claim form

Private medical insurance claim form Private medical insurance claim form *113N1A3B* Please make sure that you read the following before completing the claim form: n Confirmation of cover will be provided when we have made a decision on your

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

WageGuard Group Income Protection Claim Form

WageGuard Group Income Protection Claim Form WageGuard Group Income Protection Claim Form Frequently Asked Questions How long will it take to complete my section of the form? We ve tested it -- it takes about 20 minutes. We want to settle your claim

More information

GIO Workers Compensation Australian Capital Territory

GIO Workers Compensation Australian Capital Territory GIO Workers Compensation Australian Capital Territory Employee s claim form Employer s policy number: Complete all questions fully and accurately, to ensure accurate decisions can be made about your claim.

More information

OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form

OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form OSG Travel Claims, PO Box 1086, Belfast, BT1 9ES Email : info@osgtravelclaims.co.uk Tel: 020 7581 6444 Medical - Claim Form CLAIM No:- For Office Use Only OSG Travel Claims are committed to providing a

More information

Thank you for contacting CGU Insurance

Thank you for contacting CGU Insurance Make a Trauma Claim Thank you for contacting CGU Insurance You must have access to a printer in order to access this form. If you do not have access to a printer please contact our office on 1800 248 224

More information

Your People, Protected. Personal Accident and Sickness Cover Claim Form

Your People, Protected. Personal Accident and Sickness Cover Claim Form Your People, Protected Personal Accident and Sickness Cover Claim Form Personal Accident and Sickness Cover/Claim Form 2 Personal Accident and Sickness Cover Claim Form IMPORTANT INFORMATION We act upon

More information

Claim form for medical treatment reimbursements

Claim form for medical treatment reimbursements Claim form for medical treatment reimbursements Please complete clearly in block capitals. Information about how to complete can be found on the reverse of this form. Your claim will be processed by InterGlobal

More information

Level 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com.

Level 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com. Level 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com.au Professional Risk Underwriting Pty Ltd ABN 80 103 953 073.

More information

Complaint form. Complaint details. 1. Complainant(s) (person making the complaint) 2. Are you making this complaint on behalf of another person?

Complaint form. Complaint details. 1. Complainant(s) (person making the complaint) 2. Are you making this complaint on behalf of another person? A Complaint details Please print and cross boxes clearly. 1. Complainant(s) (person making the complaint) First name(s) Surname Residential address Postal address Telephone number (daytime) Telephone number

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

Short Term Disability Income Benefit. Employee s Guide

Short Term Disability Income Benefit. Employee s Guide Short Term Disability Income Benefit Employee s Guide Short Term Disability Income Benefits This guide contains the forms you need to apply for disability benefits and some important information about

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

INCOME CLAIM FORM FOR NON-WORK RELATED INJURY OR SICKNESS (Medical/Surgical or Specialist costs are not covered)

INCOME CLAIM FORM FOR NON-WORK RELATED INJURY OR SICKNESS (Medical/Surgical or Specialist costs are not covered) INCOME CLAIM FORM FOR NON-WORK RELATED INJURY OR SICKNESS (Medical/Surgical or Specialist costs are not covered) This INCOME CLAIM FORM FOR NON-WORK RELATED INJURY OR ILLNESS is to be returned to All Trades

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

Personal Injury Claim Form

Personal Injury Claim Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815

More information

Initial Claim Form Income Protection

Initial Claim Form Income Protection Initial Claim Form Income Protection March 2014 OnePath Custodians Pty Limited (OnePath Custodians) ABN 12 008 508 496 AFSL 238346 RSE L0000673 OnePath Life Limited (OnePath Life) ABN 33 009 657 176 AFSL

More information

UK Sickness claim form

UK Sickness claim form UK Sickness claim form Please make sure... 1. That you complete all the relevant sections and sign the claim form. 2. That you carefully read, then sign and date, sections 6.2 and 6.3 (Access to Medical

More information

LHMU Accidental Dental Claim Form

LHMU Accidental Dental Claim Form LHMU Accidental Dental Claim Form DENTAL BENEFIT CLAIM 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 completed.

More information

Workers Compensation claim form

Workers Compensation claim form Form Workers Compensation claim form STOP - this form is available to be filled in electronically on the NT WorkSafe web site www.worksafe.nt.gov.au. Fill the form in electronically then save a copy to

More information

Application for Benefits under the Motor Accidents (Compensation) Act

Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for

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

IMPORTANT INFORMATION: PLEASE READ CAREFULLY

IMPORTANT INFORMATION: PLEASE READ CAREFULLY BASKETBALL PERSONAL INJURY CLAIM FORM IMPORTANT INFORMATION: PLEASE READ CAREFULLY Dear Basketball member, Please find attached a claim form. Before lodging this form, please ensure all sections are fully

More information

Short-Term Disability Income Benefit. Employee s Statement

Short-Term Disability Income Benefit. Employee s Statement Short-Term Disability Income Benefit Employee s Statement Employee s Statement Short Term Disability Income Benefits This guide contains the forms you need to apply for disability benefits and some important

More information

ANZ Superannuation Savings Account Life Insurance Application Form

ANZ Superannuation Savings Account Life Insurance Application Form 12 March 2014 Customer Services Phone 13 38 63 Fax 02 9234 6668 Email customer@onepath.com.au Website anz.com Note: Please ensure you complete all details on this form. Any missing details will delay your

More information

Medical Cooling and Heating Electricity Concession Scheme

Medical Cooling and Heating Electricity Concession Scheme Medical Cooling and Heating Electricity Concession Scheme information brochure The Queensland Government provides financial assistance to low-income Queenslanders with a serious medical condition which

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Underwriting Australia Sports Injury Claim Form Sports Underwriting Australia Claims Department PO Box 2717, Taren Point. NSW, 2229 Tel: 1300 363 413 Fax: 02 9524 9003 Email: paclaims@sportsunderwriting.com.au

More information

Illness, injury, insurance and family be: factsheet

Illness, injury, insurance and family be: factsheet Illness, injury, insurance and family be: factsheet National Insurance Number: Date: HSC Pension Scheme Consideration of entitlement to Tier 2 Benefits. Application within 3 years of Tier 1 award. Surname

More information

Total and Permanent Disability claim form

Total and Permanent Disability claim form Total and Permanent Disability claim form 1. Notice Of Claim Written notice of claim must be given to AXA Life within 90 days from the date of disability certified by a specialist in the relevant field.

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

EMPLOYEE INCOME PROTECTION INSURANCE CLAIM FORM

EMPLOYEE INCOME PROTECTION INSURANCE CLAIM FORM Section 1 Claimant Details This form is to be completed in the event of: An insured employee being injured, or An Insured Employee suffering sickness that is covered under the company policy. Please ensure

More information

Instructions for Claimant

Instructions for Claimant Check if completed. TD Insurance Instructions f or completing the claim package for Credit Protection Critical Illness I nsurance - Life-Threatening Cancer The Credit Protection Critical Illness Insurance

More information

SPORTS INJURY CLAIM FORM NSW JUNIOR RUGBY LEAGUE

SPORTS INJURY CLAIM FORM NSW JUNIOR RUGBY LEAGUE SPORTS INJURY CLAIM FORM NSW JUNIOR RUGBY LEAGUE This information must be completed and signed by the Injured Person, a Club Official and your District Administrator and forwarded to Cunningham Lindsey

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

travel insurance travel claim report

travel insurance travel claim report claim report travel insurance travel CGU Insurance Limited ABN 27 004 478 371 An IAG Company Please retain this page for your information IMPORTANT Please read this before completing the report. Please

More information

For all claims the following documents must be sent to us along with this claim form:

For all claims the following documents must be sent to us along with this claim form: IMPORTANT: please read this before you start Use the check list below to help you complete your claims form, and identify documents you will need to attach. We don t want you to miss something. Delays

More information

Disability/Sickness Claim

Disability/Sickness Claim Genworth Financial Step 1: Check Your Policy Documents 1 Disability/Sickness Claim Building 6 Chiswick Park 566 Chiswick High Road London W4 5HR 0870 900 0161 www.genworth.co.uk Important Notes You must

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 INSURANCE CLAIM FORM FOR

PERSONAL INJURY INSURANCE CLAIM FORM FOR PERSONAL INJURY INSURANCE CLAIM FORM FOR Please ensure all sections are fully completed prior to submitting your claim. Failure to complete all sections of this form may delay settlement of your claim.

More information

Critical Illness Claim Form

Critical Illness Claim Form group insurance Critical Illness Claim Form A partner you can trust. critical illness CLAIM FORM Policyholder s statement PLEASE PRINT. TO SPEED UP PROCESSING, ANSWER ALL QUESTIONS. Policyholder s name

More information

PETANQUE FEDERATION AUSTRALIA LTD

PETANQUE FEDERATION AUSTRALIA LTD Willis Australia Limited ABN: 90 000 321 237 AFS License Number 240600 Office use only Claim Number:. PETANQUE FEDERATION AUSTRALIA LTD PERSONAL INJURY CLAIM FORM Willis Australia Limited HEAD OFFICE Level

More information

form claim Beazley AMIST Super Income Protection Australian Income Protection A Beazley Group company

form claim Beazley AMIST Super Income Protection Australian Income Protection A Beazley Group company Beazley AMIST Super Income Protection claim form Australian Income Protection A Beazley Group company Australian Income Protection Pty Ltd AFS No 289089 Beazley AMIST Super Income Protection Claim form

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Please return claim form to: Corporate Services Network 2 / 280 George Street Sydney NSW 2000 Ph: +61 2 8256 1770 Fax: +61 2 8256 1775 E-mail: claims@csnet.com.au Employer: Claimants Name: Job Title: Work

More information

ACCIDENT CASH PLAN- HOSPITALISATION CLAIM FORM

ACCIDENT CASH PLAN- HOSPITALISATION CLAIM FORM ACCIDENT CASH PLAN- HOSPITALISATION CLAIM FORM Please provide as much information as possible when completing this form. If you are unable to fit your answers into the spaces below, please continue on

More information

Claim Form for Medical Treatment Reimbursements

Claim Form for Medical Treatment Reimbursements Claim Form for Medical Treatment Reimbursements Please complete clearly in BLOCK CAPITALS. One form must be completed for each patient, for each medical condition treated. The sections marked by an asterisk

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Employer: Claimants Name: Job

More information

Wesley Mission Income Protection Claim Form

Wesley Mission Income Protection Claim Form Wesley Mission 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

More information

Motor Accident Notification Form

Motor Accident Notification Form Motor Accident tification Form This form is Approved Form AF2014-59, approved on 26 August 2014 by Karen Doran, delegate of the director-general, under section 276 of the Road Transport (Third- Party Insurance)

More information

Name of Traveller Mr Mrs Miss Ms. Occupation: Date of Birth / /

Name of Traveller Mr Mrs Miss Ms. Occupation: Date of Birth / / Travel Insurance Report Form Claim Report This issue of this form is not an admission of liability and is without prejudice. All questions in this section must be answered Name of Traveller Mr Mrs Miss

More information

Work Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days

Work Phone. Mobile / / Policy Number Date Issued Number of Travellers. Date of Booking Departure Date Return Date Total Days Travel Insurance Claim Form Cancellation You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for your claim,

More information

Maritime Super Income Protection Claim Form

Maritime Super Income Protection Claim Form Maritime Super 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

More information

Travel insurance claim form

Travel insurance claim form NTUC Income Insurance Co-operative Limited NTUC Income Centre 75 Bras Basah Road Singapore 189557 Tel: 63 INCOME/6346 2663 Fax: 6338 1500 Email: csquery@income.com.sg Website: www.income.com.sg Travel

More information

Please print out for signatures and post original to your broker if applicable or to AIG Insurance New Zealand Limited.

Please print out for signatures and post original to your broker if applicable or to AIG Insurance New Zealand Limited. Corporate Travel Insurance Claim Form Please print out for signatures and post original to your broker if applicable or to AIG Insurance New Zealand Limited. Corporate Policies Only: This section MUST

More information