JLT Sport Personal Injury Claim Form

Transcription

1 Ftball NSW Risk Prtectin Prgramme Wh shuld use this claim frm? Yu shuld cmplete this frm if: Insured - Yu are a player, umpire, fficial r vlunteer (Insured Persn) f a League/Club (the Insured) cvered within the ; and Injured - Yu sustained an accidental injury during the Plicy Perid whilst actually participating in a sanctined ftball event/activity; and Nn-Medicare - Yu are likely t incur r have incurred medical csts that are nt listed n the Medicare Benefits Scheme Befre cmpleting this frm, ensure yu are familiar with the Prduct Disclsure Statement (PDS) available n JLT Sprt s web site /FNSW. What is cvered? The s Persnal Accident cver prvides sme reimbursement fr Nn- Medicare Medical Csts and/r cver fr 12 mnths frm the date f injury. Cmmnwealth Legislatin prevents reimbursement f Medicare csts including the Medicare Gap. Nn- Medicare Medical Benefits are cvered up t the limits utlined belw. Please refer t JLT Sprt s web site fr the Prduct Disclsure Statement (PDS). Hw much can I claim? The fllwing table utlines the reimbursement capacity within the. Nn-Medicare Medical Csts 100% Reimbursement 85% Reimbursement $5,000 maximum per claim $250 maximum per week $50 excess per claim 7 day waiting perid All clubs receive the abve cverage at the cmmencement f each perid f cver. What is NOT cvered? The fllwing examples demnstrate sme areas nt cvered by the Persnal Accident cver: Medicare items (see belw); the Medicare Gap (see belw); WHAT S COVERED? NON-MEDICARE EXAMPLES: Ambulance Physitherapist Dental Private Hspital Accm. Chirpractr WHAT S NOT COVERED? MEDICARE EXAMPLES: Dctr Surgen Surgen s Assistant Anaesthetist X-Rays Public Hspitals Injuries sustained whilst playing against medical advice. Please refer t JLT Sprt s web site fr the Prduct Disclsure Statement (PDS) fr further details. What des Nn-Medicare mean? Medicare is a Cmmnwealth Gvernment prgramme that prvides free r subsidised treatment frm medical prfessinals such as dctrs and specialists. The Medicare Benefits Scheme (MBS) lists the items that are eligible fr a Medicare rebate. Smetimes, yur dctr r specialist may charge mre than the Medicare rebate, which may leave yu with ut-f-pcket expenses. This is cmmnly called the Medicare Gap. Sectin 126 f The Health Insurance Act 1973 (Cth) des nt permit the Insurer r the JLT Trustee t reimburse any part f a Medicare Item (this includes the Medicare Gap). This means that if yur treatment is listed n the Medicare Benefits Scheme, it is nt claimable thrugh the. Fr further infrmatin abut Medicare please visit r Please nte: Sme Private Health Funds may ffer Medicare Gap Insurance Cver. JLT Sprt is nt a Private Health Fund, nr d we ffer Private Health Insurance. Page 1 f 7 - JLT Sprt Persnal Injury Claim Frm 2011 JLT Sprt - Last updated: December 13

2 Hw t ldge a Persnal Injury Claim: 1. Cmplete ALL sectins f the Persnal Injury Claim Frm Yur claim frm may be returned if there is imprtant infrmatin missing Fr assistance, please cntact yur QBE Claims team; Maureen Faustin Julie Schreiber Send yur cmpleted claim frm t, r accidentandhealth@qbe.cm. 2. Within 90 days frm the date f injury. D nt wait until yur treatments have cncluded befre yu ldge yur claim Yu can ldge yur claim even if yu have n ut f pcket expenses 3. QBE will cnfirm receipt f yur claim and prvide yu with a claim number, r cntact yu shuld they require further infrmatin 4. Once yu have received yur Claim Number, yu can frward further Nn-Medicare Medical receipts t QBE as yur treatment cntinues (fr up t 12 mnths frm the date f injury). What shuld I send with my claim? Receipts - If yu have already undertaken treatments fr yur injury and incurred Nn-Medicare Medical csts please submit yur receipts t QBE. Retain a cpy - Please submit nly riginal receipts t QBE. We recmmend yu retain a cpy f all receipts and yur Claim Frm fr yur recrds. Private Health Insurance (if applicable) Please claim thrugh yur Private Health Fund first and then send QBE a cpy f yur Private Health rebate advice. Claims Cnditins: Written ntice cntaining full particulars f yur injury (as per this Claim Frm) must be submitted t QBE within 90 days frm the date f injury. Subject t the Insurance Cntracts Act 1984, any treatment must be cmpleted within 12 calendar mnths frm the date f injury. All certificates and evidence required by QBE must be prvided by yu upn request and at yur expense (if applicable). Wh is JLT Sprt? JLT Sprt is the appinted brker fr the. As a divisin f Jardine Llyd Thmpsn Pty Ltd, JLT Sprt is Australia s leading prvider f insurance and risk prtectin fr the sprt, recreatin and fitness industries Cmplete ALL sectins Send within 90 Days Dn t wait fr treatment Retain cpies f all receipts Retain a cpy f yur claim Cllectin Statement under the Privacy Act 1988: In accrdance with the Privacy Act 1988 (and subsequent amendments), we, Jardine Llyd Thmpsn Pty Ltd (and ur subsidiaries and related entities) (JLT) draw yur attentin t the fllwing: We may cllect persnal infrmatin abut yu by means f the enclsed dcument. We are cllecting the infrmatin principally fr the purpse f appraching the (re)insurance market, placing insurance, assessing and advising yu n yur insurance needs, claims handling r risk management (depending n yur requirements). Other purpses include prviding yu with infrmatin abut ther JLT prducts r services. If yu are prpsing fr r renewing insurance, the infrmatin is required pursuant t yur duty f disclsure under the Insurance Cntracts Act 1984, the Marine Insurance Act 1909 r at cmmn law. The infrmatin we cllect may be disclsed t third parties including but nt limited t (re)insurers, insurance intermediaries, service prviders, finance prviders, advisers, agents and JLT related Grup cmpanies. Thse entities will hld and use the data in accrdance with their wn privacy plicies which may include disclsure t third parties lcated ffshre. By prviding the infrmatin requested in the attached dcument, yu agree t us cllecting, using and disclsing yur persnal infrmatin as utlined in this Cllectin Statement. Thse entities will hld and use the data in accrdance with their wn privacy plicies which may include disclsure t third parties lcated ffshre. If yu d nt prvide all r part f the infrmatin requested, we may be unable t prcess yur applicatin r prvide ther required services, yur applicatin fr insurance may be declined r yu may prejudice yur insurance cver. Yu have the right t request access t, and crrect, any persnal infrmatin that we hld abut yu, subject t the prvisins f the Privacy Act T assist us in maintaining crrect recrds we ask yu t infrm us f any changes in yur persnal infrmatin prvided, as they ccur. If yu prvide us with persnal infrmatin abut ther individuals, yu must ensure that thse persns have been made aware f the abve matters. Where the infrmatin cllected relates t health, criminal recrd r ther sensitive infrmatin as defined in the Privacy Act 1988, yu must btain it with the individual s cnsent. Fr further infrmatin cntact yur JLT Client Risk Adviser r the JLT Privacy Officer: Jardine Llyd Thmpsn Pty Ltd, 66 Clarence Street, SYDNEY NSW 2000 Telephne: (02) Page 2 f 7 - JLT Sprt Persnal Injury Claim Frm 2011 JLT Sprt - Last updated: December 13

3 PERSONAL INFORMATION: Pstal Address: Street Address State Pstcde Cntact Details: Address Phne Number (Bus. Hurs) Persnal Details: / / Male Female / / AM PM Date f Birth Gender Date f Injury Time f Injury Club Name: League Name: Describe yur injury and hw it happened (please attached additinal pages if required): INJURY RESEARCH DATA: Sessin: Playing Training Travelling Event Other Warm up/dwn Lcatin: Indr Outdr Injured Persn Player Referee Official Trainer Other Grade: Senir Junir Nt Applicable Surface Type: Asphalt Cncrete Grass Indr Timber Synthetic Grass Weather Cnditins: Fine Rain Extreme Heat Extreme Cld Surface Cnditins: Wet Dry Muddy Indr Other Half: 1 st 2 nd Resumptin date(s): / / / / / / Private Health Cver: Yes N When will yu resume WORK? When will yu resume TRAINING? When will yu resume PLAYING? D yu have Private Health Insurance? If YES, what is the name f yur Private Health Insurance Prvider? Private Health Cverage: Dental Physitherapy Ambulance Hspital Ambulance Membership: Yes N PAYMENT DETAILS: Payee details: Myself Other T whm shuld we make payment? Payee Name Payee Pstal Address CLAIMANT DECLARATION: A. The injury was sustained accidentally during a ftball activity and is nt a pre-existing illness r cnditin. B. Yu have viewed, read and understd the Prduct Disclsure Statement (PDS) at /FNSW. C. Yu understand that the Health Insurance Act 1973 (Cth) prhibits the Trustee and Insurer frm reimbursing csts that are registered with Medicare (including the Medicare Gap). D. Yu acknwledge and agree t the infrmatin cntained herein (including persnal infrmatin) being shared with authrised members f JLT, the insurer and the Claims Managers. E. Yu authrise any hspital, physician r ther persn wh has attended t yur injury, r any emplyer, t furnish QBE s representatives with any and all infrmatin with respect t any sickness r injury, medical histry, cnsultatin, prescriptins, treatments, cpies f all hspital r medical recrds and cpies f emplyment recrds. F. Yu agree that a phtcpy r electrnic versin f this authrisatin shall be cnsidered as effective and valid as the riginal. G. Yu declare that the frging particulars are true and accurate in every detail. Yu agree that if yu have made, r shall make, in any further declaratin regarding this injury, any false r fraudulent statements r suppress r cnceal r falsely state any material whatsever, the cvers shall be vid and all rights t recver there under fr past r future injuries shall be frfeited. H. Yu authrise any and all infrmatin regarding claims with any ther insurer t be released t JLT's representatives. Claimant s Signature* *Parent r Guardian if under 18 years Date: / / Page 3 f 7 - JLT Sprt Persnal Injury Claim Frm 2011 JLT Sprt - Last updated: December 13

4 CLUB DETAILS: Club Name: Club Cntact: Club Cntact Persn Psitin within Club Cntact Details: League Name: INJURY DETAILS: Cntact Phne Number Address Date/Time: / / AM PM Date f Injury Time f Injury Circumstances: Playing Training Travelling Other Oppsitin Club Name: Grund/Lcatin: If applicable Where did the injury ccur? Resumptin date(s): Yes N / / Has the Claimant returned t TRAINING? If YES, date Claimant returned? Yes N / / Has the Claimant returned t COMPETITION? If YES, date Claimant returned? CLUB DECLARATION: A. Yu are an authrised representative f, and yu are acting n behalf f, the Claimant s Club r League (as abve). B. After reasnable inquiry, yu cnfirm the injury details supplied herein are true and accurate. C. Yu declare the Claimant s injury was sustained accidentally during the ftball activity nted abve and is nt a preexisting illness r cnditin. Club Representative s Signature: Date: / / Page 4 f 7 - JLT Sprt Persnal Injury Claim Frm 2011 JLT Sprt - Last updated: December 13

5 TO BE COMPLETED BY THE CLAIMANT: D yu wish t claim Benefits? Yes N If NO, prceed t SECTION D If yu are NOT claiming Benefits please d nt cmplete this sectin. Please prceed t Sectin D. Can yu claim cmpensatin frm any ther plicy that includes lss f incme benefits (such as Wrkers Cmpensatin)? Yes N Have yu ever made previus claims in respect t a persnal accident insurance plicy r plan? Yes N Have yu engaged in any ther incme earning emplyment since yu became injured? Yes N TO BE COMPLETED BY THE CLAIMANT S EMPLOYER (OR ACCOUNTANT IF SELF-EMPLOYED): Emplyer/Business: Emplyer/Cmpany Name Cntact Persn Pstal Address: Cntact Details: Street Address State Pstcde Address Phne (Bus. Hurs) Mbile Emplyment Status: Full Time Part Time Casual Self Emplyed Emplyment Details: $ $ / / Emplyee s NET weekly salary Emplyee s GROSS week salary Date Emplyee cmmenced with cmpany. If Self-Emplyed r Casual, please prvide average weekly salary based n 12 mnth perid directly prir t injury. Injury Details: / / / / Date emplyee ceased wrk Date expected t resume duties Returned t Wrk: Yes N / / Has the Emplyee returned t wrk? Salary Received: Yes N If YES, what fr? If YES, what date did the Emplyee return? During the perid f incapacity, has the emplyee received a salary? Sick Leave: Yes N frm / / t / / Annual Leave: Yes N frm / / t / / Other: Yes N frm / / t / / Net f business expenses, persnal deductins and incme tax; excludes bnuses, cmmissins and all ther allwances. Excludes incme derived frm playing sprt. EMPLOYER S DECLARATION: A. Yu are the Claimant s current emplyer (r accuntant if the claimant is self-emplyed), B. After reasnable inquiry, yu cnfirm the emplyment and salary details supplied herein are true and accurate, C. Yu will supply upn request any further infrmatin as required fr the determinatin f this claim. Emplyer s Signature: Date: / / * Accuntant s signature (if claimant is self-emplyed) Fr mre infrmatin, please refer t JLT Sprt s web site: /FNSW Page 5 f 7 - JLT Sprt Persnal Injury Claim Frm 2011 JLT Sprt - Last updated: December 13

6 This sectin must be cmpleted (in full) by yur attending physician. An attending physician includes a general practitiner, physitherapist, chirpractr r dentist. PHYSICIAN S REPORT Physician s Details: THIS SECTION MUST BE COMPLETED WITHOUT EXPENSE TO JLT SPORT Physician s Name Injury Cnsultatin: / / / / Diagnsis/Histry f injury: Date f Injury Date f Cnsultatin Phne Number Injury Lcatin: Ankle Arm Dental Facial Ft Hand Head Internal Knee Lwer Leg Shulder Spinal Trs Upper Leg Please mark ( ) the anatmical lcatin belw: Injury Type: Amputatin Bruising Cncussin Cut Death Dental Dislcatin Fracture/Break Rupture Sprain Strain First Medical Treatment: / / Date f treatment Fatigue/Debilitatin Name f attending physician D yu cnsider the Claimant s injury t be a NEW injury? Yes N D yu cnsider the Claimant s injury t a recurrence f a previus injury? Yes N If YES, please prvide details and a descriptin: Des the Claimant have any cngenital defects r chrnic deases? Yes N If YES, please prvide details and a descriptin (dates, name f treating dctr, etc): Please cntinue t Page 7. Page 6 f 7 - JLT Sprt Persnal Injury Claim Frm 2011 JLT Sprt - Last updated: December 13

7 PHYSICIAN S REPORT (cntinued) Have yu referred the patient t any ther services r treatment? Yes N If YES, please prvide details belw: Physitherapy: Yes N Chirpractics: Yes N Surgery: Yes N Other: Yes N If YES, apprx. number f treatments required. If YES, apprx. number f treatments required. If YES, please prvide details If YES, please prvide details Has the Claimant been able t d any wrk since the injury ccurred? Yes N What date d yu advise the Claimant t return t playing Ftball? / / If YES, please prvide details PHYSICIAN S DECLARATION: A. Yu have examined the Claimant s injury as described n this frm; B. Yu declare that all infrmatin prvided by yu and supplied herein is true and accurate. Physician s Signature: Date: / / LOSS OF INCOME CLAIMS ONLY The fllwing Incapacity t Wrk Statement must be cmpleted by a qualified Medical Practitiner (i.e. General Practitiner, Surgen r a Specialist). It will nt be accepted if cmpleted by a Physitherapist, Chirpractr, etc. INCAPACITY TO WORK STATEMENT: I, examined n / / Medical Practitiner s Name Claimant s Name Date f examinatin In my pinin, this persn is/has been unfit t wrk frm / / t / / inclusive. First day f incapacity Please prvide any further cmments in regard t yur assessment f the injury/cnditin? Last day f incapacity A. Yu have examined the Claimant s injury as described n this frm; B. Yu declare that all infrmatin prvided by yu and supplied herein is true and accurate. Medical Practitiner s Signature: Date: / / Fr mre infrmatin, please refer t JLT Sprt s web site: /FNSW Page 7 f 7 - JLT Sprt Persnal Injury Claim Frm 2011 JLT Sprt - Last updated: December 13