INCOME PROTECTION CLAIMS CLAIM FORM FOR THE SELF EMPLOYED

Transcription

1 PENSIONS INvESTMENTS LIFE INSURANCE INCOME PROTECTION CLAIMS CLAIM FORM FOR THE SELF EMPLOYED If ou are an Emploe Person o not complete this form. Please ring our Insurance Broker or Irish Life irectl for the appropriate form. Please rea ever question carefull an complete ever item on this form in BLOCK CAPITALS.If an item is blank or illegible, this ma cause a ela in processing our claim. If ou are unsure about an item, ou shoul ask our plan aviser. This forust be full complete an returne to the Income Protection Claims Team, Irish Life, no later than 2 calenar months before the en of the eferre perio. Details of our eferre perio will be in our plan booklet. A Meical Certificate must also be furnishe without expense to Irish Life. The issue of this claim form is in no wa an amission of liabilit. Please provie as much information as possible. This will enable us to process the claim quickl. Warning: Proviing false information on this form coul result in our claim being rejecte an all cover being cancelle. Section 1: Personal Details Name of Business Polic number Name of Claimant Home Aress aress Telephone Number Mobile Number Date of Birth / / Male Female Civil Status Marrie Single Wiow(er) Separate Divorce Civil Partner Former Civil Partner PPS number PPS Number shoul contain 7 igits an 1 or 2 letters. This is require as Irish Life ma be responsible for eucting an tax ue on an benefit paable. Business Aress Business Tel. Number Business Mobile No Bank Account Details Account number (IBAN) SWIFT BIC - - Name/Names of Account Owners Bank Name Bank Aress Bank Account Details will onl be use if, following assessment, a ecision is mae to amit the claim an a pament is ue. Please note that we will require the following for ientification: A vali, unexpire full legible cop of photo ientification (e.g. passport or river s licence) an A full legible cop of current aress ientification (e.g. recent utilit bill, official letter or statement ate within the last 6 months) Have ou enclose appropriate forms of ID? es no Section 2: Occupational Details 1. How long have ou been Self Emploe? 2. Are ou: (a) Engage on our own account as a sole traer? es no (b) A partner personall acting in some trae, profession or occupation? es no Page 1

2 Section 2: Occupational Details Continue 3. Are an famil members involve in the business? es no If es, please give etails to inclue the exact nature of their involvement 4. What was our precise occupation(s) ieiatel prior to isablement? 5. Please escribe our normal uties in etail 6. Please confirm if our job involves an of the following? (a) walking es no hrs per a (b) staning es no hrs per a (c) bening es no hrs per a () sitting es no hrs per a (e) climbing (i.e. laers/stairs) es no hrs per a (f) lifting es no hrs per a Max. wts. lifte Avg. wts. lifte (g) riving es no hrs per a Mileage p.a. vehicle tpe. 7. Please avise whether an special licences are require for ou to carr out the occupation. 8. Are an special skills require? If es, please give full etails. es no 9. What specific tools/equipment woul ou normall use? 10. In what environmental conitions woul ou normall expect to be working? (eg office, factor, an extremes of heat or col, outoors etc). 11. How man hours woul ou normall expect to work uring the week? hrs per week 12. Does the job involve an unsocial hours? If es, please give full etails. es no Page 2

3 Section 2: Occupational Details Continue 13. Do ou supervise an other staff? If es, how man. es no No. of staff 14. Please provie etails of an qualifications ou have obtaine or courses ou have attene in relation to this job or an other occupation. 15. Please provie full etails of our job histor. 16. Is the business still traing? If no, please confirm the exact ate on which the business cease traing. es / / no 17. Have ou incurre an aitional staff costs ue to our current isabilit? If es, please give full etails. es no 18. Have ou mae an plans to resume our normal occupation? If es, please avise when ou expect to o so. es no Section 3: Financial Details 1. Name of Accountant Accountant s Aress Telephone Number Mobile Number 2. Please ask our accountant to: (a) provie copies of our accounts an copies of income tax assessments in respect of the 3 ears ieiatel prior to isablement. If the accounts an/or income tax assessment for the most recent ear have not et been prepare, please ask our accountant to confirm in writing when these will be available. (b) confirm in writing whether or not ou are currentl receiving an income from the business since our isabilit began. NB: Please note we will not be in a position to consier our claim without this information. Section 4: Accient Details (please complete this section if our isabilit is a result of an accient) 1. Please escribe where the accient occure Date of accient / / 2. Please escribe the exact nature an cause of the accient. Page 3

4 Section 5: Meical Details (to be complete b all claimants) 1. Please escribe in etail below the conition or isabilit which ou are currentl suffering from? Please escribe in etail below the conition or isabilit which ou are currentl suffering from? 2. What was the nature of the initial smptoms an when i the first occur? 3. Exact ate on which ou stoppe working? / / 4. Are ou restricte b our isabilit? If es, please escribe below how ou are restricte. es no 5. What meication are ou currentl taking? Please inclue osage. 6. Are ou having an non-rug therap? e.g. phsio, counselling or alternative meicine. es no If es, please give etails an names an aresses of practitioners. 7. Are ou using an phsical ais e.g. walking sticks or collars? If es, please give full etails. es no 8. Is our current treatment proviing an relief of smptoms? If es, please give full etails es no 9. Has there been an improvement in our conition? If es, please give full etails. es no 10. Have ou iscusse returning to our previous job with our GP or Specialist? If es, please give full etails. es no Page 4

5 Section 6: Meical Attenant Details Please list the full names an aresses of all octors/specialists who are currentl treating ou or who have treate ou in the past for these problems. Date first Date last Date of next Name, Aress & Specialit of Doctor/Consultant attene attene appointment / / / / / / / / / / / / / / / / / / / / / / / / Section 7: Hobbies an Pastimes 1. What are our present hobbies or pastimes? 2. Are ou able to continue with these? es no 3. Have ou evelope an new interests since our isabilit began? If es, please give full etails. es no Section 8: Previous Disablement Have ou previousl suffere from the above isablement or an other sickness or injur for more than 4 weeks? es no If es, please give full etails with approximate ates an perios of incapacit. Section 9: Emploment Since Disabilit Note: The polic conitions provie for a reuce benefit to be pai in certain circumstances. Examples of these circumstances coul inclue our return to our normal occupation on a part-time basis or taking up an alternative occupation at lower earnings. However, it is extremel important that ou notif Irish Life in avance if ou o so, as failure to isclose this information coul result in our claim being rejecte an all cover ceasing. Please ring Income Protection Claims in Irish Life on if ou require an further etails. 1. Since our isabilit began, have ou: (a) Unertaken ANY of the uties of our normal occupation? es no (b) Unertaken ANY other work (whether pai or not)? es no If ou have answere es to either of the above, please confirm the following: (c) Exact nature of work performe () Date of coencement / / (e) Hours worke per month (f) Monthl Earnings (g) Name of emploer (h) Are ou still working? es no If no, when i ou stop? / / 2. If ou have been unable to unertake an work whatsoever, please avise when ou anticipate that ou ma be able to o so? hrs per mth Page 5

6 Section 10: Other Benefits Are ou insure against accient or sickness with an other insurance compan (incluing mortgage isabilit policies)? es no If es, please confirm the following: Name of Compan Polic Number Start ate of polic Yearl amount of benefit per ear / / Start ate of benefit / / Deferre perio Section 11: Previous Claims Have ou previousl ha a isablit claim with Irish Life or an other compan? If es, please give etails. es no Section 12: Awars 1. Are ou currentl pursuing a thir part claim in connection with this isablement? es no 2. If es, please avise (a) Date proceeings issue? (b) Date Thir Part notifie? / / / / (c) What stage are proceeings at? Section 13: Social Welfare Benefits Are ou entitle to an social welfare benefits? es no If so, are ou currentl in receipt of an benefits? es no Please list each tpe of benefit an weekl amount iniviuall /wk /wk /wk Have ou been require to atten for meical assessment b the Department of Social & Famil Affairs es no meical referee? If es, what was the outcome? If es, please provie the ate of the examination. / / If no, is an examination planne? es no If ou have not been meicall approve for benefit b the Department of Social & Famil Affairs, are ou appealing es no this ecision? If es, please provie full etails. Page 6

7 Section 14: Aitional Information Please state an aitional information which ma be of assistance in the ongoing management of this claim. Section 15: Declaration I eclare that to the best of m knowlege an belief, the information given in this claim form is true an complete an that I am the person referre to in the particulars given. I full unerstan that I must notif Irish Life ieiatel, if I resume m normal occupation either on a full time or part time basis, or if I take up an alternative work whether pai or not, as failure to o so will result in ieiate termination of the claim an cover ceasing. I unerstan that to process m claim Irish Life nee to have specific consent to seek further information. I freel consent to Irish Life obtaining information from, an/or sharing relevant information, in the context of this claim with, an octor or other health professional nominate b Irish Life in relation to the assessment an/or management of m claim or who at an time has attene me concerning anthing which affects m phsical or mental health. This ma inclue the time prior to m application for cover a Health Claims Avisor if a home visit is arrange an insurance office insuring me for Income Protection or similar benefits whether I have mae a claim or not m emploer, solicitor, accountant or other similar source which Irish Life eem necessar in relation to the assessment an management of this claim I authorise Irish Life to obtain, process an share this information. Signature Date / / Please also sign the aitional consent section below which will be sent to the octor, health professional, insurance office or other source when obtaining information. Data provie as part of the processing of our claim will be maintaine b Irish Life in line with the provisions containe in the Data Protection Acts 1988 an Please Note Irish Life provies a home visit service an an appointment ma be mae b a Health Claims Avisor to meet with ou to iscuss our claim. If such a meeting is arrange, an information provie b ou together with an observations mae b the Health Claims Avisor will form part of our claim ata an the information will be maintaine in line with the provisions of the Data Protection Acts as above. Irish Life ma use Private Investigators. Each Private Investigator must ahere to a strict coe of practice an complete a compliance certificate. The are expecte to compl at all times with the Data Protection Acts an not perform their functions in such a wa as to cause Irish Life to breach an of its obligations uner the Data Protection Acts. An unauthorise processing, use or isclosure of personal ata b Private Investigators is strictl prohibite. Irish Life Assurance plc is regulate b the Central Bank of Irelan. Irish Life Corporate Business, Lower Abbe Street, Dublin 1, Irelan. T: 01 Page F: Section 16: Consent to obtain Information I unerstan that, to process m claim, Irish Life nee to have specific consent to seek further information. I freel consent to Irish Life obtaining information from an octor or other health professional who at an time has attene me concerning anthing which affects m phsical or mental health. This ma inclue the time prior to m application for cover a Health Claims Avisor if a home visit is arrange an insurance office insuring me for Income Protection or similar benefits whether I have mae a claim or not m emploer, solicitor, accountant or other similar source which Irish Life eem necessar in relation to the assessment an management of this claim I authorise Irish Life to obtain, process an share this information. Signature Date / / Page 7

8 Irish Life Assurance plc is regulate b the Central Bank of Irelan. In the interest of customer service we ma recor an monitor calls. Irish Life Assurance plc, Registere in Irelan number , Vat number 9F55923G. Irish Life Corporate Business, Lower Abbe Street, Dublin 1, Irelan. T: F: CONTACT US! PHONE: FAX: [email protected] WEBSITE: WRITE TO: Irish Life Corporate Business, Lower Abbe Street, Dublin cb (rev 3-15) Irish Life Assurance plc is regulate b the Central Bank of Irelan. In the interest of customer service we ma recor an monitor calls. Irish Life Assurance plc, Registere in Irelan number , vat number 9F55923G. Page 8