Income Protection CLAIM FORM

Transcription

1 Inome Protetion CLAIM FORM PLEASE COMPLETE THIS APPLICATION IN BLACK PEN ONLY USING BLOCK LETTERS 1 PERSONAL DETAILS Poliy numer Important notes: a This form must e ompleted in full and returned to PO Box 1692, Wellington 6140, without delay so we an promptly assess any laim entitlement. Completion of this form is at your expense. It is your responsiility to otain all information requested. Failure to omplete this form in full or provide other requested information may result in delays in assessing any entitlement. Title Given names(s) (plea se print) Surname Male Female Date of irth RESIDENTIAL ADDRESS OF LIFE INSURED Contat name for orrespondene Street numer and name Suur Town/City Postode Country Home phone Business phone Moile phone address ( ) ( ) ( ) POSTAL ADDRESS OF LIFE INSURED (If different from aove) Street numer and name/po Box Suur Town/City Postode Country Do you have medial insurane? If yes, name the insurer 2 ACCIDENT DETAILS This setion to e ompleted if the laim is in respet of an aident a When did the aident our? Date Time am/pm Where did the aident our? State the nature and extent of your injury. If to a lim state whether left or right. d e Is your laim overed y Workers Compensation Insurane/ACC? What treatment/rehailitation are you undergoing for this injury? f Who is your Insurer in respet of this aident? Please supply your Insurer s postal address along with details and opies of supporting doumentation verifying your laim entitlement and progress. The National Mutual Life Assoiation of Australasia Limited, (Inorporated in Vitoria, Australia), PO Box 1692, Wellington. Memer of the Gloal AXA Group. 1 S6133/DS2072/0508

2 a 3 SICKNESS DETAILS This setion to e ompleted if the laim is in respet of a Sikness Desrie your symptoms? Date of onset of these symptoms? Have you ever had the same or similar symptoms efore? If yes, give date, ontat details and the name of the dotor or hospital that treated you 4 WORK CAPACITY DETAILS a Are you urrently limited y your disaility? If yes, desrie your limitations When did you stop work in your usual oupation? am/pm on Give details Did you ease work solely due to sikness or injury? d Did you ease work on this date on medial advie? If no, explain a 5 TREATMENT DETAILS Name of your usual dotor Address Does this dotor hold your full medial history notes? If no, advise the name of the dotor(s) who would hold this information Who was the treating dotor who first treated you for this sikness or injury? (Give name and address and when/where you were first treated for this sikness/injury). Date of first onsulation d Date of susequent onsulations e Have you seen other medial professionals aout your sikness/injury? If yes, give details and dates 2 The National Mutual Life Assoiation of Australasia Limited, (Inorporated in Vitoria, Australia), PO Box 1692, Wellington. Memer of the Gloal AXA Group.

3 f Have you reeived any treatment for your sikness/injury? If yes, give details and date g Have you een hospitalised for your sikness/injury? If yes, give details and dates of your admission and disharge Admission Disharge Provide a opy of your disharge form 6 INCOME DETAILS (Exept Rural Inome Protetion plans) a Are you: (tik appropriate) self employed (sole trader, partner) a salaried employee ontrator unemployed a salaried employee for a ompany in whih you have a finanial interest If you are a waged or salaried worker, state your gross earnings for any onseutive 12 month period over the last 36 months. Name and address of your employer Provide verifiation of your inome from your employer y way of a wage slip, opy of your employment ontrat, tax return and tax assessment. d If you are self employed, a ontrator or have a finanial interest in a ompany of whih you are also an employee, omplete the following: Desrie your usiness sole trader ompany partnership Partnership in the partnership there are urrently partners and my perentage interest in the usiness is % Provide details of the ontratural agreement etween partners. Company there are urrently numer of shareholders and my shareholdoing is on a ratio of I reeive remuneration from the ompany y way of shareholder salary dividends diretors fees other e f g Name of usiness Numer of full time employees Numer of part time employees The National Mutual Life Assoiation of Australasia Limited, (Inorporated in Vitoria, Australia), PO Box 1692, Wellington. Memer of the Gloal AXA Group. 3

4 i Has your usiness eased trading sine you eame disaled? If yes, i provide date of essation ii If no, have you or any family memers een involved in the ontinued running of the usiness? Provide details of the finanial arrangement j Have you ought or sold any usiness during the six months prior to the date you are laiming from? If yes, please provide details k Provide verifiation of inome details, finanial statements, tax returns and assessments. l Gross inome less usiness expenses for a onseutive 12 month period over the past 36 months Gross inome from personal exertion efore tax Business expenses inurred in earning that inome Net inome less equals Taxale inome NOTE: Business expenses plan: provide verifiation of expenses fixed and ongoing, 12 months immediately prior to your disaility m While you are disaled, will you reeive or are you entitled to reeive any inome from the following soures? If yes, please give the monthly amounts Workers Compensation Insurane, ACC Your employer Your usiness (inlude any inome generated net of expenses) Any other disaility poliy Inome support servies Any superannuation fund or group sheme Any other soure Total monthly amount n Have you ever made a laim under the Workers Compensation Insurane At/ACC or any other disaility poliy efore? If yes, give details o Have you een disaled through aident or sikness this year? If yes, how many days sik leave did you reeive? days p Are you entitled to reeive sik leave for your present disalement? If yes, how many days? days 4 The National Mutual Life Assoiation of Australasia Limited, (Inorporated in Vitoria, Australia), PO Box 1692, Wellington. Memer of the Gloal AXA Group.

5 7 OCCUPATION DETAILS a What is your oupation? Business/employer s name Business/employer s address d Provide details of your oupation(s) over the last five years inluding periods of unemployment, eginning with your urrent oupation. From To Oupation Employer/name of usiness month year month year e Did you work prior to eoming disaled? f How many hours per day/week were you working prior to your disaility? per day per week g List your duties efore you eame disaled; e.g. staff supervision 20%, administration 10%, manual laout 30%, sales 40% = 100% i ii iii iv v vi vii viii TOTAL % efore disaility h Sine your injury/sikness, have you een: (tik appropriate ox) ale to perform your usual oupation unale to perform your usual oupation ale to do partial work, if yes advise date you ommened work i State details of duties you are ale to do j How many hours did you work eah week following the inapaity? Week Hours worked Amount earned per week week 1 week 2 week 3 week 4 week 5 week 6 k When do you expet to return to your usual oupation? Please provide dates Part time Full time The National Mutual Life Assoiation of Australasia Limited, (Inorporated in Vitoria, Australia), PO Box 1692, Wellington. Memer of the Gloal AXA Group. 5

6 PRIVACY ACT 1993 ( The At ) Personal information olleted in onnetion with this Appliation will allow AXA New Zealand to evaluate and proess the Appliation and to administer the Poliy and/or laim and may also e used to provide you with information aout other produts or servies offered y AXA New Zealand. Under the At you have the right to aess and orret any personal information aout you. The personal information will e held y AXA New Zealand at 80 The Terrae, Wellington. Authorities COLLECTION OF INFORMATION I authorise any dotor, health professional, hospital or medial institution, who has or may e, onsulted y me to give AXA New Zealand any information it may require. RELEASE OF Information I authorise my employer, any government department, other insurer, or other person who holds information relevant to the assessment of this laim inluding, ut not limited to, information aout my sikness/injury, my employment history, to provide to AXA New Zealand any information it may require. I also authorise AXA New Zealand to release all medial information and any other relevant information pertinent to the laim to any person they require me to onsult with in respet of the laim or any person engaged y AXA New Zealand in onnetion with the management of the laim. A photoopy of this authority will e suffiient evidene of my onsent to suh release. DECLARATION I herey delare that the statements in this form are true and orret in every respet and that I have not astained from engaging in or attending to any profession, usiness or oupation either totally or partially longer than asolutely neessary as a result of injury or sikness. I will provide AXA New Zealand suh further evidene of my laim as may reasonaly e required. If any answer is not in my handwriting, I delare that it has een written down at my ditation. Name of Life Insured Signature Date BANK ACCOUNT DETAILS If the laim is aepted, entitlement will e diretly redited to this aount. Please supply details of your ank aount. Attah a deposit slip of ank aount details as verifiation. Attah your deposit slip here. ADVISER INVOLVEMENT If you would like your finanial adviser to e involved with the progress of your laim, sign the authorisation elow. I authorise AXA New Zealand to release all relevant information pertinent to my laim to my finanial adviser. Name of finanial adviser Signature Date 6 The National Mutual Life Assoiation of Australasia Limited, (Inorporated in Vitoria, Australia), PO Box 1692, Wellington. Memer of the Gloal AXA Group.

7 Certifiate of Medial Attendant FORM Poliy numer To the Medial Attendant: a This medial ertifiate and requested information must e ompleted in full and returned to PO Box 1692, Wellington Completion of this form is at your patient s expense. Please supply photoopies of the patient s full history notes, inluding any reports and results of investigations. 50 ents per page of photoopying will e paid y AXA New Zealand, please inlude an itemised aount. 1 Title Given name(s) (please print) Surname 2 Patient s date of irth 3 Patient s urrent oupation 4 Nature of sikness or injury 5 If appliale, please give a DSM-IV diagnosis. (Provide a opy of the assessment) 6 Cause of injury (if appliale). 7 How long has the patient suffered from this ondition? 8 Date of first onsultation and treatment in respet of this ondition. 9 Dates of susequent onsultations and treatment in respet of this ondition. 10 Advise the date on whih you advised the patient to ease work solely due to their sikness or injury. 11 What is your proposed treatment plan? 12 Has the patient een referred or are you onsidering refering the patient to any other treating pratitioner for further opinion, investigation or treatment? 13 Has the patient een hospitalised? If yes, when were they admitted Disharged 14 Is this patient still under your are for this ondition? If no, state i the date disharged from your are ii the name of the treating dotor The National Mutual Life Assoiation of Australasia Limited, (Inorporated in Vitoria, Australia), PO Box 1692, Wellington. Memer of the Gloal AXA Group. 7 S6133/DS2072/0508

8 15 Is there any ompliating fator affeting or extending this ondition? (eg: family, work situation, other disorders) 16 In your opinion was the injury or sikness aused or aggravated y the patient s oupation, sport or pastime? 17 If you are not the patient s regular treatment provider, state the name and address of the patient s regular treatment provider. 18 How long has this person een a patient of your pratie? 19 Has the patient ever suffered from the same or any other disease or ondition related to this disalement? 20 Has previous treatment een given prior to this period of disalement? If yes, state dates 21 Have you issued a ertifiate or ompleted any other reports regarding this injury or sikness? 22 Is, or has the patient een unale to attend his/her usual oupation solely due to sikness or injury? If yes, state the dates From To 23 Is, or has the patient een partially disaled? If yes, state how long the patient was or will e ontinuously partially disaled, so that he/she is prevented from attending to a material portion of the daily duties pertaining to his/her oupation. Indiate the numer of hours per week the patient is apale of working. State the date the patient is apale of returning to their work 24 In your opinion, what rehailitation is appropriate for your patient and how an we support this? 25 Any other omments? I onfirm that I have examined this patient and the information provided is orret and omplete. Dotor s name Qualifiations Address Telephone ( ) Fax ( ) 8 Dotor s signature The National Mutual Life Assoiation of Australasia Limited (Inorporated in Vitoria, Australia) PO Box 1692, Wellington. Memer of the Gloal AXA Group. Be Life Confident Date S6133/DS2072/0508