Income Protection Initial Claim Form

Transcription

1 MLC Insurance Income Protection Initial Claim Form MLC Nominees Pty Limited ABN AFSL RSE L The Universal Super Scheme ABN R Superannuation Fund Number MLC Limited ABN AFSL Please fully complete this claim form (pages 1 to 7). If there is insufficient space to fully answer a question, please use page 6. Please also arrange for your doctor to complete the Treating Doctor s Report (pages 8 to 10). Scheme Name or Employer (Business) Name Policy Number/Member Number A. Disability Details 1 Describe the exact nature of your medical condition/s. member Details Mr Mrs Ms Miss Other Surname (Family Name) (please print) Given Name(s) (please print) 2 When did the symptoms of your medical condition/s first appear? 3 When did you first consult a doctor for this medical condition/s? Date of Birth Home address Country of Birth 4 When was your last day at work? 5 Did you stop work because of your medical condition? No Please advise why you stopped work: Postal address (if different to home address) Go to question 6 Home telephone number Work number 6 Is your condition the result of an accident? No Go to question 8 How, where and when did the accident occur?: ( ) ( ) Mobile number What is your height and weight? height (cm) weight (kg) 7 Was the accident reported (eg to your employer, the police etc)? No Go to question 8 Please provide details: Page 1 of 10 Income Protection Initial Claim Form

2 8 Provide the name and address of your usual doctor and/or surgery and the date of your most recent consultation. Name of Doctor/Surgery and Speciality 12 Were you admitted to hospital for this medical condition? No Go to question 13 Provide details below Name of Hospital/Doctor and Speciality Telephone Number ( ) Date last consulted Reason for admission 9 How long have you been attending this doctor and/or surgery? (days) (months) (years) 10 Please advise details of all healthcare providers (eg, doctors, physiotherapists etc), you have consulted and the date first and last consulted for your medical condition (please use page 6 if space is insufficient). Admission date Discharge date 13 What treatment has been prescribed by your treating doctor/s? Type of treatment/medication Name of Doctor/Surgery and Speciality Dosage/frequency Prescribed by Name of Doctor/Surgery and Speciality 14 Have any tests been conducted or recommended? No Go to question 15 Provide details below Type of test/s 11 Which doctor and/or surgery would best know the complete history of your medical condition? Dates of test/s Test Results Name of Doctor/Surgery and Speciality 15 Has any further treatment been recommended? No Go to question 16 Please advise type of treatment: Page 2 of 10 Income Protection Initial Claim Form

3 16 Have you ever had this or any similar/related medical condition/s? No Go to question 17 Provide details below 20 Describe your work duties in detail, including the type of duties and and percentage of time doing manual and/or non-manual work. Describe type of duties Nature of condition/s Date of episode/s Period/s off work from to from to Name of doctor consulted Percentage of Manual work % Percentage of Non-Manual work % 21 Which duties of your occupation are you not able to perform because of your disability? 17 Do you have any other medical conditions for which you are receiving treatment? No Go to question 18 Please provide details 22 Which duties of your occupation are you still able to perform despite your disability? 23 Prior to your disability, what were your usual hours and days of work in a week? B. Occupation and Income Details Hours worked per week Usual days worked per week 18 What was your job title and who was your Employer at the time you ceased work? Hours worked per day From am/pm To am/pm 19 Provide the name and address of your employer or business (if self-employed). 24 What was your annual income from your full time occupation for the past 12 months, before tax, and net of business expenses (if applicable)? Do not include investment income. Annual Income $ Net of business expenses $ 25 Do you have any other source of income (eg, sick leave, investment etc)? No Go to question 26 Type of income Amount $ Page 3 of 10 Income Protection Initial Claim Form

4 26 Indicate below if you are self-employed or an employee? Self-employed Go to question 27 Employee Go to question 28 (c) Will you have a job to return to at the end of your disability? No Please advise why this is the case: Complete Question 27 ONLY if you are Self-Employed: 27 Have you worked in the business in any capacity since your disability began? No What has happened to the business in your absence? Provide details below Type of work Full time Part time Date started Date ceased Income earned $ Go to question 29 c. other 29 Are you making a claim, or have you ever made a claim for this condition under workers or accident compensation, third party insurance or with Centrelink, Department of Veterans Affairs, or any other insurance company or government department? No Go to question 30 Provide details below Insurer/Department name Complete Question 28 (a to c) ONLY if you are an Employee: 28 (a) Since your disability began have you worked for your employer in any capacity? No Go to question 28 (b) Provide details below Claim type (eg Workers Comp) Duties performed Contact person Claim number Gross Weekly Benefit $ Full time Part time Date started Date ceased 30 Describe your current daily activities (please use page 6 if space is insufficient). Employer s (Business) name Income earned $ 31 What daily activities are you unable to do because of your medical condition/s? (b) Have you continued to receive any income (eg, sick leave, wages, etc) from your employer since your disability began? Type of work Income earned $ Page 4 of 10 Income Protection Initial Claim Form

5 32 Please provide details of any sports/pastimes you have that you have been unable to continue because of your medical condition? 33 Have you returned to work? No When do you expect to return to work? Full time Part time When did you return to work? Full time Part time 34 Provide any other comments which may assist with the assessment of your claim. Page 5 of 10 Income Protection Initial Claim Form

6 ADDITIONAL INFORMATION: If you use this page to provide additional information, please note the page and question number to which the additional information refers. Page Number Question Number Additional Information Page 6 of 10 Income Protection Initial Claim Form

7 Disclosure to Client Representative To assist with the claims process you may want a family member or friend to receive information regarding your claim. I acknowledge that the information provided may include any information that MLC Limited (MLC) holds about me in respect of my claim including health, lifestyle, employment, financial, and insurance information. I authorise the people listed below to receive information on my behalf about my claim. They have been made aware and have consented to their personal details (name, date of birth and relationship to me) being given to MLC. I have also provided them with a copy of the brochure sent to me by MLC which details how MLC handles personal information and privacy. 1 Name Relationship to me Date of Birth 2 Name Relationship to me Date of Birth Declaration and Authority 1 I declare that the answers on pages 1 to 7 are true and complete. I have not made any false or misleading statement and I have included all information relevant to the assessment of my claim. 2 If any answers to the questions are not in my handwriting I certify that I have checked them and they are correct. 3 I understand that if I do not give the information requested by MLC or its representative that MLC may not be able to assess, investigate or pay my claim. 4 I understand that MLC will disclose, collect and use the information covered by this Declaration and Authority solely for the purpose of its administration of the policy, including this claim, and not for any other purpose. 4.1 I hereby authorise MLC to disclose my personal information (which may include sensitive or health information) to the following parties. I further consent to these parties collecting information about me and releasing to MLC their report, including any information they may hold about me as relates to MLC s administration of the policy, including this claim to: Any physician, hospital or any other healthcare provider who has attended or examined me in order for them to supply MLC with full particulars of my medical history including copies of all hospital or medical records, referral letters, reports and details of any clinical notes that have been made. Any claims assessor, investigator, medical professional, healthcare provider, insurance reference service, credit reference service, legal or accounting firm, auditor, employer, consultant or reinsurer for the purposes of producing a report concerning my claim. Any benefit provider such as other insurers or government departments (including workers compensation insurers, Centrelink or similar benefit providers) that provides benefits in the event of my sickness and/or injury. 4.2 I authorise MLC to provide my Financial Adviser with copies of all correspondence (which may include personal and sensitive information) between MLC and myself in respect of the claim. I also authorise my Financial Adviser to make inquiries regarding the progress of the claim for the purpose of providing me with ongoing service. 5 A photocopy of this authority is as valid as the original. Name of Member (please print) Signature Date Please attach copies of any reports and/or test results relating to your current medical condition you may have in your possession. Return this form and any attachments to: Claims Department MLC Limited PO Box 200, North Sydney NSW 2059 Page 7 of 10 Income Protection Initial Claim Form

8 MLC Insurance Income Protection Initial Claim Form Treating Doctor s Report MLC Nominees Pty Limited ABN AFSL RSE L The Universal Super Scheme ABN R Superannuation Fund Number Any charge for completion of this form is the patient s responsibility. MLC complies with Privacy Legislation. MLC Limited ABN AFSL Scheme Name or Employer (Business) Name 7 What are the patient s current symptoms? Policy Number/Member Number patient s Details Mr Mrs Ms Miss Other Surname (Family Name) (please print) Given Name(s) (please print) Date of Birth 1 Patient s occupation 2 How long has the patient been attending you and/or your surgery? (days) (months) (years) 3 Are you the patient s usual medical attendant? No 4 When did you first see the patient for the current medical condition? 5 When did the patient s symptoms first appear or the injury occur? 8 Provide the history of the patient s medical condition. Please include dates of all consultations for this condition, details of treatment and results of any tests or investigations undertaken. Please attach copies of any test results, if available. Date of consultation: Consultation details and treatment: 9 Has the patient required hospital treatment? No Go to question 10 Name of hospital Provide details below Name of Doctor and Speciality Reason for admission 6 What is the patient s diagnosis and date of diagnosis? Date of diagnosis: Admission date Discharge date Page 8 of 10 Income Protection Initial Claim Form

9 10 Has the patient ever had the same or a similar condition before? No Go to question 11 Please provide details: 14 Has the patient been partially disabled (ie. able to work part time or in a reduced capacity in current occupation)? No Go to question 15 For what period? From To What work duties has the patient been unable to do? 11 Have any other doctors been consulted for this condition(s), or have you referred the patient to any other doctors for a further opinion, treatment or investigation/s for this condition(s)? No Go to question 12 Provide details below Name of Doctor and Speciality Field of expertise 15 Is the patient still disabled? No When did the patient return to work? Full time Part time When do you consider the patient will be fit to return to work? Full time Part time 16 Provide any other details and/or additional comments. Referral date if applicable 12 In respect of the patient s medical condition, have you issued any certificates to any other insurance company, or for workers compensation, Dept of Veterans Affairs or Centrelink? No Go to question 13 To whom? 13 Has the patient been totally disabled (ie not able to work in current occupation and not working)? No Go to question 14 For what period? From To What work duties has the patient been unable to do? Page 9 of 10 Income Protection Initial Claim Form

10 Declaration and Authority I hereby certify that I have personally attended the above patient and that all the information supplied by me on this form is true and complete. I acknowledge that: this information is provided for the primary purpose of the assessment and investigation of a claim under a policy with MLC Limited (MLC); MLC may provide copies of this form to third parties, for example medical specialists or claims assessors from whom MLC seeks an independent report or to any other person deemed necessary to assist in the assessment or investigation of this claim. Name (please print) Qualifications Telephone number ( ) Signature Date Please attach copies of any reports and/or test results relating to the patient s current medical condition you may have in your possession. Return this form and any attachments to: Claims Department MLC Limited PO Box 200, North Sydney NSW MLC 06/09 Page 10 of 10 Income Protection Initial Claim Form

11 MLC Insurance Income Protection Employer s Statement MLC Nominees Pty Limited ABN AFSL RSE L The Universal Super Scheme ABN R Superannuation Fund Number If there is insufficient space to fully answer a question, please use page 3. MLC complies with Privacy Legislation. MLC Limited ABN AFSL Scheme Name or Employer (Business) Name 4 What were the employee s usual hours and days of work in a week? Hours worked per week Usual days worked per week Policy Number/Member Number Hours worked per day Employee Details Mr Mrs Ms Miss Other Name of Employee From am/pm To am/pm 5 Provide details of all leave taken during the 2 years prior to ceasing work (include dates and types of leave). Please provide a payroll print out including dates and reasons for leave. Please use page 3 if space is insufficient. Date of Birth Date commenced employment Date joined scheme Date of accident or commencement of illness Salary at date last worked $ Date the employee was last actively at work Reason the employee ceased work Claim Details Type of leave Dates from to Type of leave Dates from to Type of leave Dates from to 6 Were the employee s usual hours/days or duties modified in any way before they stopped work? No Go to question 7 Please provide details and number of people supervised: 1 Please provide a precise description of the injuries or nature of the illness and details of related leave already taken. 2 Employee s job title and description of duties (please provide a copy of the Job Description). 7 Please provide a full description of any previous positions the employee held with your organisation, including the periods spent in each position. Please use page 3 if space is insufficient. Previous position Dates from to Previous position 3 Was the employee: Full time Part time Casual Contractor Dates from to Previous position Dates from to Page 1 of 3 Income Protection Employer s Statement

12 ADDITIONAL INFORMATION: If you use this page to provide additional information, please note the page and question number to which the additional information refers. Page Number Question Number Additional Information Page 2 of 3 Income Protection Employer s Statement

13 8 When do you expect the employee to be able to: (i) carry out alternative duties? (ii) return to work on a part time basis? (iii) return to work on a full time basis? 10 Any other comments which you believe are relevant to the assessment of this claim. 9 Provide details of any workers compensation claims this employee is currently making, or has made in the past. Workers compensation insurer name Claim Number Claim start date Contact person Gross Weekly Benefit $ Time off work to Medical Condition Workers compensation insurer name Declaration I declare that I am authorised to answer the above questions on behalf of the employer, and that to the best of my knowledge the above statements are true and correct. I acknowledge that: this information is provided for the primary purpose of the assessment and investigation of a claim under a policy with MLC Limited (MLC); MLC may provide copies of this form to third parties, for example medical specialists or claims assessors from whom MLC seeks an independent report or to any other person deemed necessary to assist in the assessment or investigation of this claim. Where this claim is made under a superannuation fund, I authorise MLC Limited to release a copy of this document and any information provided to the Trustee of the Fund Name of signatory (please print) Claim Number Signature under Common Seal or Rubber Stamp Job Title Claim start date Contact person Date Gross Weekly Benefit $ Time off work to Medical Condition Contact telephone number ( ) Please return this form to: Claims Department MLC Limited, PO Box 200, North Sydney NSW MLC 06/09 Page 3 of 3 Income Protection Employer s Statement

14 Section A: To be completed by the PAYEE 1 What is your tax file number (TFN)? See Privacy of information on the next page. 2 What is your name? Title: Surname or family name First given name Other given names Tax file number declaration This declaration is NOT an application for a tax file number. Please print neatly in BLOCK LETTERS and use a BLACK pen. Print X in the appropriate boxes. Please ensure you read all the instructions prior to completing this declaration. Mr Mrs Miss Ms 3 If you have changed your name since you last dealt with the Tax Office, show your previous family name 4 What is your date of birth? 5 What is your home address in Australia? OR I have made a separate application/enquiry to the Tax Offi ce for a new or existing TFN. OR I am claiming an exemption because I am under 18 years of age and do not earn enough to pay tax. OR I am claiming an exemption because I am a pensioner. Day Month Year 6 On what basis are you paid? (Select only one.) Full-time employment Part-time employment 7 Are you an Australian resident for tax purposes? Labour hire Superannuation income stream No Casual employment You must answer No at question 8. 8 Do you want to claim the tax-free threshold ONLY CLAIM THE TAX-FREE from this payer? THRESHOLD FROM ONE PAYER. If you have more than one source of income and currently claim the tax-free threshold from another payer, do not claim it now. Answer No at questions 9 and 10 unless you are a non-resident No claiming a senior Australians, zone or overseas forces tax offset. 9 Do you want to claim family tax benefit or the senior Australians tax offset by reducing the amount withheld from payments made to you? Complete a Withholding declaration, but only if you are claiming the tax-free threshold from this payer. If you have more than No one payer, please contact the Tax Office on Do you want to claim a zone, overseas forces, dependent spouse or special tax offset by reducing the amount withheld from payments made to you? Complete a Withholding declaration. No 11 (a) Do you have an accumulated Higher Education Loan Programme (HELP) debt? Your payer will withhold additional amounts to cover any compulsory repayments. No (b) Do you have an accumulated Financial Supplement debt? Your payer will withhold additional amounts to cover any compulsory repayments. No Suburb or town DECLARATION by payee: I declare that the information I have given is true and correct. Signature Date Day Month Year State There are penalties for deliberately making a false or misleading statement. Once this form is completed and signed, send the original to the Tax Office and keep your copy in a secure place. Section B: To be completed by the PAYER 1 What is your Australian business number (ABN) (or your withholding payer number if you are not in business)? What is your registered business name or trading name (or your individual name if not in business) NAT Branch number (if applicable) 2 If you don t have an ABN or withholding payer number, have you applied for one? No T H E U N I V E R S A L S U P E R SCHEME DECLARATION by payer: I declare that the information I have given is true and correct. Signature of payer Date Day Month There are penalties for deliberately making a false or misleading statement or failing to forward the original to the Tax Offi ce. Year 4 What is your business address? M I L L E R ST Suburb or town NORTH SYDNEY State 5 Who is your contact person Business phone number M A S T E R K E Y S E R V I C E S If you no longer make payments to this payee, print X in this box Return completed original Tax Offi ce copy to: For WA, SA, NT, VIC or TAS For NSW, QLD or ACT Australian Taxation Offi ce Australian Taxation Offi ce PO Box 795 PO Box 9004 Albury NSW 2640 Penrith NSW 2740 TAXPAYER-IN-CONFIDENCE (when completed) Please estimate the time taken to complete section B. mins

15 PRIVACY OF INFORMATION The Income Tax Assessment Act 1936 authorises the Tax Office to request information in this declaration. The information will help the Tax Office administer the laws relating to tax, and help other government agencies administer other legislation covering Australian Government benefits and superannuation. All information the Tax Office collects, including personal information, is treated as confidential and is protected by the Income Tax Assessment Act 1936 and the Privacy Act The Tax Office may give this information to other government agencies as authorised by the tax laws, for example, Australian Government agencies that administer laws relevant to your particular situation. Depending on your situation, these agencies could include Centrelink, the Australian Federal Police, the Child Support Agency, the Department of Veterans Affairs, the Department of Immigration and Multicultural and Indigenous Affairs, the Department of Family and Community Services and the Department of Education, Science and Training. If you quote your tax file number (TFN) to your payer, in some circumstances they may, and in others must, give your TFN to your superannuation fund. Only certain people and organisations can ask for your TFN. These include employers, some Australian Government agencies, trustees for superannuation funds, payers under the pay as you go (PAYG) system, higher education providers, the Child Support Agency and investment bodies such as banks. Section 202C of the Income Tax Assessment Act 1936 authorises the Tax Office to request quotation of your TFN on this declaration for the purposes of administering tax laws. It is not an offence not to quote your TFN, but there may be consequences if you do not, for example, you may have extra tax withheld. If you need more information about how the tax laws protect your personal information, or have any concerns about how the Tax Office has handled your personal information, phone between 8.00 am and 6.00 pm, Monday to Friday.

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18 MEDICAL AUTHORITY SALARY CONTINUANCE CLAIM I... (full name) hereby authorise any hospital, physician, healthcare provider, employer, accountant or insurer, to furnish MLC Limited or its representatives, any and all information with respect to any sickness or injury, medical history, consultation, prescriptions, or treatment and copies of all hospital records. I agree that a photocopy of this authorisation shall be considered as effective and valid as the original. I understand that this may include confidential medical information which is irrelevant to the claim. Where this claim is in connection with a superannuation fund, I authorise MLC Ltd to release any information obtained under this authority to the trustee of this fund. Signed. Name (Please print). Dated. Doctor s Name:.. :..... Phone No:.. MLC Limited A.B.N

19 If you do not own a document from this section, then provide documents from either Part B or Part C below. Tick () Select only ONE document from this section Australian State/Territory driver s licence containing a photograph of the person Australian passport (a passport that has expired within the preceding 2 years is acceptable) Australian card issued under a State or Territory for the purpose of proving a person s age containing a photograph of the person Foreign passport or similar travel document containing a photograph and the signature of the person* If you do not own a document in Part A above, please provide TWO documents from Part B. Tick () Tick () Select ONE document from this section; AND Australian birth certificate Australian citizenship certificate Australian pension card issued by Centrelink Australian health card issued by Centrelink Select ONE document from this section A document issued by the Australian Commonwealth or a State or Territory within the preceding 12 months that records the provision of financial benefits to the individual and which contains the individuals name and residential address. A document issued by the Australian Taxation Office within the preceding 12 months that records a debt payable by the individual to the Commonwealth (or by the Commonwealth to the individual), which contains the individuals name and residential address. A document issued by an Australian local government body or utilities provider within the preceding 3 months which records the provision of services to that address or to that person (the document must contain the individuals name and residential address). If under the age of 18, a notice that was issued to the individual by a school principal within the preceding 3 months and contains the name and residential address and records the period of time that the individual attended that school. If you do not own a document in Part A or Part B, please provide BOTH documents from Part C. Tick () Select BOTH documents from this section Foreign driver s licence that contains a photograph of the person in whose name it is issued and the individuals date of birth* Foreign national identity card issued by a foreign government containing a photograph of the person in whose name the card was issued* * Documents that are written in a language that is not English, must be accompanied by an English translation prepared by an accredited translator. WHO CAN CERTIFY DOCUMENTS The following persons are authorised to certify documents: A Justice of the Peace A judge of a court A magistrate A chief executive officer of a Commonwealth court A registrar or deputy registrar of a court A person who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described) A notary public (for the purposes of the Statutory Declaration Regulations 1993) A police officer An agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public A permanent employee of the Australian Postal Corporation with 2 or more years of continuous service who is employed in an office supplying postal services to the public An Australian consular officer or an Australian diplomatic officer (within the meaning of the Consular Fees Act 1955) An officer with 2 or more continuous years of service with one or more financial institutions (for the purposes of the Statutory Declaration Regulations 1993) A finance company officer with 2 or more continuous years of service with one or more finance companies (for the purposes of the Statutory Declaration Regulations 1993) An officer with, or authorised representative of, a holder of an Australian financial services licence, having 2 or more continuous years of service with one or more licensees A member of the Institute of Chartered Accountants in Australia, CPA Australia or the National Institute of Accountants with 2 or more years of continuous membership. ACCEPTABLE CERTIFICATION OF ID DOCUMENTS Each copy of the ID must be certified by the approved certifier as follows: The approved certifier must write the following on each photocopy: This is a true copy of the original document(s) which I have sighted: Full Name eg Michelle Helena Citizen; Contact address and telephone number; Date of certification; Signature; The capacity in which they have certified the document eg judge, magistrate, police officer, etc); Affix the official stamp or seal of the certifier s organisation. Proof of Identity 1 of 1

20 Privacy Notification MLC Limited and its subsidiaries are members of the National Australia Group (the Group). The Group includes banking, financing, funds management, financial planning, superannuation, insurance, broking and e-commerce organisations. This statement is an outline of certain matters relating to the collection and handling of your personal information by Group organisations. Collecting your personal information Group organisations will collect personal information for the purposes of: providing you with a product or service (including assessing your application) managing and administering the product or service identifying you and protecting against fraud verifying your authority to act on behalf of a customer determining whether a beneficiary will be paid a benefit upon a person s death letting you know about products or services from across the Group that might better serve your financial, e-commerce and lifestyle needs or promotions or other opportunities in which you may be interested. If you provide MLC with incomplete or inaccurate personal information, the Group organisation may not be able to process your requests and applications or manage or administer your products or services. It may also not be possible to tell you about other products or services from across the Group that might better serve your financial, e-commerce and lifestyle needs. Using and disclosing your personal information Group organisations may disclose your personal information to other organisations: involved in providing, managing or administering the products and services the Group offers, including third-party suppliers (eg printers, posting services), other Group organisations, its advisers and loyalty and affinity program partners who are your financial or legal advisers or representatives and their service providers involved in maintaining, reviewing and developing the Group s products, business systems, procedures and infrastructure including testing or upgrading the Group s computer systems involved in a corporate re-organisation or involved in a transfer of all or part of the assets or business of a Group organisation involved in the payments system including financial institutions, merchants and payment organisations which are Group organisations which wish to tell you about their products or services that might better serve your financial, e-commerce and lifestyle needs or promotions or other opportunities, and their related service providers, except where you tell the Group not to as required or authorised by law and/or where you have given your consent. Your personal information may also be used in connection with such purposes. Because the Group operates throughout Australia and overseas, some of these uses and disclosures may occur outside your state or territory and outside Australia. Gaining access to your personal information Subject to some exceptions allowed by law, you can gain access to your personal information. If access is denied, you will be given reasons for this. In some cases, your request may be dealt with over the telephone. For more information To find out more information about your personal information and privacy, please call the MLC Client Service Centre on M0110