INCOME PROTECTION InsURANCE INITIAL CLAIM form

Transcription

1 INCOME PROTECTION InsURANCE INITIAL CLAIM for Sales Person: Agent/Agency No.: We need the inforation in this for, together with any other edical or financial evidence which ay be requested, so that we ay establish a clear picture of your situation. Failure to answer any question will delay consideration and possibly settleent of your clai. If you fail to disclose a aterial fact or if you give false inforation you could invalidate your clai and render your policy void. It is therefore essential that you provide accurate and coprehensive answers. Please read your policy schedule and conditions before copleting this for. Answers ay be continued on a separate sheet if necessary. Please note that a private investigator ay be appointed to investigate the validity of a clai. Please forward the copleted for to us at the address below together with: 1. Evidence of age (Birth certificate, passport or driving licence) 2. Evidence of incoe (A P60 or notice of assessent and relevant accounts for the period prior to the date of disability) 3. Job description 4. GP clai for along with any edical reports or letters that you ay have available fro your doctors Health Clais Departent, Friends First Life Assurance Copany Ltd., Cherrywood Business Park, Loughlinstown, Dublin 18 SECTION 1. PERSONAL DETAILS Mr./Mrs./Ms. Surnae: Marital Status: First Nae(s): Date of birth: Address: Height: Weight: Hoe Tel. No: Mobile Nuber: Eail address: Policy Nuber: P.P.S. Nuber: How any dependent children do you have?: Ages of dependent children: Is your spouse eployed?: Yes No Spouse s Occupation: SECTION 2. YOUR EMPLOYMENT 1. Who was your eployer(s) iediately prior to disability? Full Nae: Address: 2.(a) What was your occupation(s) iediately prior to this disability? (b) Please describe your noral duties in detail. AF257,Mar. 09

2 SECTION 2. YOUR EMPLOYMENT Continued (c) What special skills were required? (d) How any staff were under your control? 3.(a) In what environent did you work (e.g. office, outdoors, factory, etc.)? (b) Is a driving licence necessary for your job? Yes: No: If so which type: (c) What achines, equipent or tools did you operate? (d) Are there any environental conditions that aggravated your disability (e.g. dust, weather, etc.)? Yes: No: If yes, please give details: 4. Did your noral working day involve: (please tick as appropriate) No Occasionally regularly (a) Clibing ladders or siilar? (b) Carrying or lifting heavy ites? (c) Standing? (d) Crawling or Kneeling? (e) Driving? (f) Walking 1/4 ile or ore? (g) Any other Physical Exertion? If so, please specify: 5. (a) Did your job involve travelling, apart fro travelling to work? Yes: No: If Yes, how any iles a week did you travel? (b) What for of transport did you use? 6. (a) What hours did you work? per week (b) Are there any unusual aspects of your hours of work (e.g. shift work, weekend work or being on call )? (c) When did you coence this eployent? Start Date: Please give details of any other eployent(s) you have had during the last five years: (If none, please say so). Start Date: Job titles(s): Brief description of duties: Nae of eployer (or if self-eployed): End Date: Start Date: End Date: Start Date: End Date:

3 SECTION 3. YOUR DISABILITY 1. (a) What is your disability? (b) Was this due to an accident? Yes: No: If yes, please give date, tie, place and a full description of the accident: (c) Do you intend to seek copensation or instigate proceedings against any person as a result of your accident or illness, or have you already done so? Yes: No: If Yes, please provide full details including the nae and address of your solicitor: 2. (a) When was your last day at work? If date (b) is ore than seven days after date (a), please tell us why: (b) When did you first seek edical advice about this? (c) Who have you seen in connection with this disability, e.g. GP, Specialist, Copany Doctor,etc? Nae and address GP/Specialist Date first attended Date last attended Date of next appointent (d)what edication have you received/are you receiving? (e) What treatent have you received/are you receiving e.g. physio, counselling, etc? (f) Is your current treatent providing any relief of syptos? Yes: No: If yes, please give details: (g) Has there been any iproveent in your condition? Yes: No: If yes, please give details:

4 SECTION 3. YOUR DISABILITY Continued 3. (a) What parts of your job are you (or were you) unable to do? (b) Are you still unable to do the? Yes: No: If No, please give date of recovery: (c) Have you done any part of your own or any other job, whether paid or unpaid, since the date you have given in question 2(a) (and before the date in 3(b) if applicable)? Yes: No: If Yes, please give details: If No, when do you think you will be fit enough to go back to work? (d)is your job still available for you to return to? Yes: No: (e) Is there alternative work available should you be able to return to a less deanding activity? If so please give details: 4. Have you suffered fro this or any siilar condition before? Yes: No: If Yes, please give details, (including dates and who you consulted): 5. What were your hobbies and pasties prior to your disability and are you able to continue the? (If No please confir why this is the case) SECTION 4. YOUR INCOME PRIOR TO DISABILITY 1. Fro Eployent. (a) Please give your gross earned incoe as declared for tax purposes for the period of one year up to the coenceent of your disability. Please enclose a copy of your last P60 2. Fro Self-Eployent. (a) Please give details of your business. No. of Nae: Address: Telephone nuber: No. of Partners Eployees (b) Please enclose your latest available Agreed Notice of Assessent fro the Revenue Coissioners and the related Certified Accounts. (c) Please give your taxable net incoe for the period of one year up to the coenceent of your disability (estiated if necessary). (d) Please coent on any significant differences between the incoes indicated in (b) and (c) above. (e) Please provide us with the nae and address of your Accountant:

5 SECTION 5. YOUR INCOME DURING DISABILITY 1. State Benefits (a) Are you entitled to any State benefits? Yes: No: (b) What benefit have you received since the end of the deferred period? Illness Benefit: Invalidity Pension (for a single person): Adult Dependant benefit: Children s benefit: Any other State benefits: Please specify type of benefit: (c) Have you been required to attend for edical assessent by the Departent of Social Welfare? Yes: No: If yes, what was the outcoe? If no, is an exaination planned? Yes: No: Date of exa: (d) If you have not been edically approved for benefit by the Departent of Social Welfare, are you appealing this decision? Yes: No: If yes, please provide details. If your clai for State benefits has been rejected, please enclose copies of any relevant letters. 2. Other Insurances (a) Do you hold any other insurance against disability (including Personal Sickness and Accident policies)? Yes: No: (You should include any policies where benefit is yet to be paid). If Yes, please provide the following details in respect of each policy: Nae of insurer: Policy nuber: Deferred period: Benefit per week: weeks weeks weeks weeks (b) Have you previously had a disability clai with Friends First or any other copany? Yes: No: If yes, please give full details. 3. Other Incoe (Ignore investents) (a) Have you received any other incoe since the end of the deferred period? (You should include any continuing salary, pensions, coissions, etc.) Yes: No: (b) Are you expecting to receive any other incoe in the future? Yes: No: Note: If you were self-eployed you should include any continuing incoe you have received fro your business. If the answer to either of 3(a) or 3(b) is Yes, please provide details: Aount per week: Start date: finishing date: pw Aount per week: Start date: finishing date: pw

6 SECTION 5. YOUR INCOME DURING DISABILITY CONTINUED (c) Are you a sole trader? Yes: No: (d) Are you in a partnership? Yes: No: If a partner, please confir your % share of the business % (e) If you were self-eployed, has your business ceased since you becae disabled? Yes: No: If No, please give details of any additional expenses you have incurred in aintaining the business: Aount: Aount: pw pw reason: reason: SECTION 6. BANK DETAILS Benefits payable under this policy will be paid by Electronic Fund Transfer (EFT) to the relevant back account. Please provide your bank account details below. Please note that you do not need to provide your bank account details if you are a eber of an eployer paid group schee, as any benefit payable will be paid to your eployer s bank account. Bank nae: Bank address: Bank account nae: Bank account nuber: Sort code: Sign here Date: PLEASE CHECK THAT YOUR ANSWERS ARE ACCURATE AND THAT NOTHING HAS BEEN OMITTED. Is there anything else that ight be helpful to us in assessing your clai? PLEASE SIGN THE DECLARATION ON THE FOLLOWING PAGE.

7 SECTION 7. DECLARATIONS 1. I hereby declare that I a the person referred to in the particulars given, that I have read over the replies to all of the questions in this for, that to the best of y knowledge and belief all the inforation given is true, and that I have not withheld any aterial fact. 2. I fully understand that I ust notify Friends First iediately if I resue y noral occupation either on a full tie or part tie basis, or, if I take up alternative work, whether paid or not, as failure to do so could invalidate y clai and render y policy void. 3. I hereby consent to the use and recording of y personal details (contained herein) by both electronic and printed eans to Friends First Life Holdings Ltd, in accordance with the Data Protection Acts 1988 and 2003 as aended. Signed: Date: 1. I consent to Friends First seeking inforation in connection with this clai fro any doctor or edical professional who has at any tie attended e and I authorise the giving of such inforation. 2. I consent to Friends First seeking inforation in connection with this clai fro any insurance office to which a clai has been ade and I authorise the giving of such inforation. 3. I consent to Friends First seeking inforation in connection with this clai fro any other relevant person or persons, including but not liited to y accountant, solicitor, eployer and I authorise the giving of such inforation. Signed: Date: Full nae (Please print in block capitals)

8 Friends First Life Assurance Copany Ltd Friends First House Cherrywood Business Park Loughlinstown Dublin 18 Fro sustainably anaged forests - For ore info: Friends First Life Assurance Copany Liited is regulated by the Financial Regulator. In the interest of custoer service and to ensure the accuracy of our records calls will be recorded and onitored.