Wesley Mission Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields completed. Incomplete forms will be returned to obtain missing information. Please also provide a signed photocopy of your current driver s license or passport to verify your identification. It is essential that you provide us with the name and address of your Medical Practitioner(s) for the past 5 years, as requested in SECTION A Claimants Statement. A wage report is to be provided from your employer detailing each weekly/fortnightly wage for the 12 months prior to the date of your total disablement, as requested in Section C Employment. If your claim is for a psychiatric condition, we require a report from a psychiatrist supporting your claim. Medical certificates need to be original and must state the condition for which you are claiming. In relation to Workers Compensation/Compulsary Third Party claims, please provide an Acceptance/Decline letter and if liability has been accepted please provide copies of all benefits. If you are in receipt of Centrelink or any other benefits as a result of your condition, please provide copies of all benefits paid. Australian Income Protection Pty Ltd AFS No. 289089 P a g e 1
Wesley Mission Income Protection Claim Form Please do not complete this form unless you have been or will be off work for at least 21 days. Instructions: 1. Section A is to be completed by you, the claimant. 2. Section B is to be completed by your treating doctor. 3. Section C is to be completed by your employer. 4. Please enclose original medical certificates. If your condtition is in anyway related to a psychological illness, we require a supporting medical report to be provided from your treating Psychiatrist/Psychologist. 5. Please provide a signed photocopy of your current drivers license or passport to verify your identification. 6. Mail completed form to: Australian Income Protection Pty Ltd C/- Beazley Underwriting Pty Ltd Attention: Claims Department GPO Box 2761, Brisbane QLD 4001 7. If have any enquiries please call Australian Income Protection Pty Ltd on (07) 3228 1618 IMPORTANT NOTICE Any fraud, misstatement or concealment by you in relation to any matter affecting this insurance in connection with making of any claim under it, will give us the rights provided for in the Insurance Contract Act, including where appropriate the right to reduce or refuse payment of any claim. All questions must be completed and claim form signed before claim will be processed. (Please print) Title: First name(s): Last name: Suburb State: Postcode: Phone: ( ) Mobile: Fax: ( ) Email: Date of birth: / / Gender: Male Female Australian Income Protection Pty Ltd AFS No. 289089 P a g e 2
Section A Claimant s Section Employment details: Name of Community Service / Facility: Address of Community Service / Facility: Suburb: State: Postcode: Work ph: ( ) Work fax: ( ) Email: Length of employment: Years: Months: Occupation: Please list your day to day work duties/activities you are required to perform: Percentage of Manual Work: % Percentage of Non-Manual Work: % Is heavy lifting required in your role?: What is your average gross weekly earnings?: $ Prior to your injury/sickness, what were your usual hours and days of work in a week? Hours worked per week: Usual days worked per week: Hours worked per day: From: am/pm To: am/pm Medical Information: Is your condition: Injury: Sickness: Date of injury or first symptoms of sickness: / / Time occured: am/pm Name and extent of injury/sickness: If injured, please state what you were doing and how it happened: Have you suffered from this injury/sickness before?: Date previous injury/sickness occured: / / If Yes, please provide details: Was/Is surgery required for current condition?: If Yes, when was/is the surgery?: / / Date you first sought medical attention for current condition: / / Australian Income Protection Pty Ltd AFS No. 289089 P a g e 3
Section A Claimant s Section Name and address of your medical Practitioner(s) for the past 5 years: You must fully complete your medical practitioner s information below or your claim may be delayed up to 10 weeks while we obtain a full Medicare history report. Name: Suburb: State: Postcode: Ph: ( ) Fax: ( ) Date first attended: / / Date last consulted: / / Years attended: Name: Suburb: State: Postcode: Ph: ( ) Fax: ( ) Date first attended: / / Date last consulted: / / Years attended: (If you have visited more than 2 medical practitioners over the last 5 years provide the information attached to this claim form.) Additional Benefits Checklist: (please tick either Yes or No to each question) If you answer Yes to any of the below, please provide proof of claim / benefit. For example: provide acceptance letter, decline letter and copies of benefits paid. Have you or will you lodge a motor accident claim?: Was your injury/sickness work related?: If Yes, have you or are you going to lodge a claim for Workers Compensation?: Insurance Co for Workers Comp: Are you receiving any additional benefits from your employer?: Sick leave: Annual/holiday leave: Long service leave: Other: Have you or will you lodge a claim with Centrelink?: Have you or will you lodge a claim for any sports insurance benefit?: Have you or will you lodge any other type of insurance claim?: If Yes, please provide details below: Insurance company: Policy number: Contact details: Type of policy: Australian Income Protection Pty Ltd AFS No. 289089 P a g e 4
Section A Claimant s Section Australian Income Protection (a Beazley Group Company) Claimant Consent & Authority Declaration I declare I am the person named on this form or I have a power of attorney to act on the claimant s behalf. I declare that the information provided in this form, to the best of my knowledge and beliefs are true and correct and if any answers to the questions completed in this form are not in my handwriting, I have certified that I have checked them and they are also correct. I understand that if I have made or make any false, misleading or fraudulent statements, conceal or intentionally withhold relevant information for the assessment or ongoing review of this claim, Australian Income Protection a Beazley Company may: * Refuse to pay this claim; * Recover benefits paid that were based on false or misleading information I provided; and / or * Be obliged to refer such case to relevant Authority. I declare and authorise that I have read and understood the Privacy information provided with this form and I understand that my personal and sensitive information, may be disclosed to other parties as advised below and approve these purposes. I hereby authorise and direct any medical attendant, Doctor, Hospital or other medical or health service to divulge to Australian Income Protection a Beazley Company, its representatives or any legal tribunal, and to release at any time details of my personal medical history, including referrals to or treatment by any other Practitioners, any health or other information acquired with regard to myself for the purposes of allowing Australian Income Protection a Beazley Company to assess my claim or assess any new, additional insurances (including re-instatements). I also authorise my current and any previous Employer to release to Australian Income Protection a Beazley Company any personal or health information requested to facilitate an assessment of my claim. Under Government Privacy Legislation, I may access a copy of any reports provided to Australian Income Protection a Beazley Company. I authorise Australian Income Protection a Beazley Company to obtain from Medicare such portion of my claims history deemed necessary by Australian Income Protection a Beazley Company to properly assess my claim. I also authorise the Institutions listed below to provide to Australian Income Protection a Beazley Company any health and other personal information that Australian Income Protection a Beazley Company considers essential and/or reasonable to further assess or evaluate my claim. I further authorise Australian Income Protection a Beazley Company to contact, release and obtain information it requires to assess my claim for benefits, from those other sources it considers necessary including, but not limited to the following: Any Doctor, ambulance, hospital or other health service provider; My employer, previous employer/s, accountant/s and/or Financial Advisers and/or Union Delegate or Representative; Medicare, the Insurance Commission including PBS records; Any Insurance Company, including Workers Compensation Insurer; Insurance or financial reference agencies, re-insurers, financial institutions including banks, credit unions, building societies, mortgage providers, finance companies, (and Claims investigators) Private Investigators and Detectives and Forensic Accountants; Government Agencies, including but not limited to Centrelink, Australian Taxation Office, Australian Securities and Investments Commission, Department of Veterans Affairs and Department of Immigration and Citizenship; Any Federal, State or Territory Police Department; Traffic Accident Commission (Victoria), State and Territory Roads and Traffic Authorities, Queensland Transport, Vic Roads Registration and Licensing Office, Transport South Australia; and Any other Institution that holds my personal information. I understand that Australian Income Protection a Beazley Company may be required to submit all documentation to a mediator, Solicitor, Complaints Resolution Tribunal or Court or to any other person necessary for claims determination purposes including the Trustee of any Superannuation Plan. I understand a determination of my claim may not be possible if I withhold consent and authority for Australian Income Protection a Beazley Company to seek personal and/or health information in relation to my claim. I agree that a scanned, photocopied or faxed copy of this authority shall be considered as effective and valid as the original. Signature of Claimant: Name of claimant (Please Print): Date: / / Australian Income Protection Pty Ltd AFS No. 289089 P a g e 5
Section A Claimant s Section Claim form check list: Have all sections been completed? Have you provided a signed photocopy of your current drivers license or passport? Have you supplied a list of all treating doctors over the last 5 years? Has your employer supplied a report showing a breakdown of weekly wages for the 12 months preceding the date of incapacity? Your claim will be delayed unless all sections are complete. Send the completed form to: Australian Income Protection Pty Ltd C/- Beazley Underwriting Pty Ltd Attention: Claims Department GPO Box 2761, Brisbane QLD 4001 Australian Income Protection Pty Ltd AFS No. 289089 P a g e 6
Section B Doctor s Section Please have this section completed by your regular treating doctor that you have seen for this condition. Patients Details: (Please print) Title: Last name: First name(s): Suburb: State: Postcode: Age: Date of birth: / / Is the claimant s condition: Injury: Sickness: Date of injury or onset of sickness: / / Date you were first consulted: / / Date diagnosed: / / Date incapacity commenced: / / Date claimant was first aware of symptoms: / / Are you the claimant s usual doctor: If yes, how long have they been attending your practice: Years: Months: Please list dates of all consultations in relation to the patient s condition: 1. / / 2. / / 3. / / 4. / / 5. / / 6. / / 7. / / 8. / / Injury/sickness details: Please provide your diagnosis of their condition: Please provide an outline of their symptoms: In your opinion, what caused the current condition: Please provide an outline of past treatment : Please outline your recovery/treatment plan: History: Australian Income Protection Pty Ltd AFS No. 289089 P a g e 7
Section B Doctor s Section In your opinion, is the injury or sickness work related? : Estimated date of return to work on restricted duties: / / Estimated date of return to work on normal duties: / / Is the patient s current condition related to any previous Injury/Sickness? If so, did you treat the patient for the injury/sickness? Has the claimant been referred to a specialist for his/her problems?: If Yes, could you please supply the contact details? Name: Suburb: State: Postcode: Ph: ( ) Fax: ( ) In your opinion, does the patient require surgery for the condition?: If yes, has the patient already undertaken the surgery?: Date surgery was undertaken: / / Medication/Treatment: Has the claimant been taking medication for their condition?: If yes, please state the medication and the date prescribed: Date: / / Medication: Date: / / Medication: Date: / / Medication: Date: / / Medication: Have you advised the patient, that their condition no longer requires any treatment or ongoing medical supervision, including the use of any prescribed medication? If Yes, on what date was that advice given?: / / What is your prognosis? Australian Income Protection Pty Ltd AFS No. 289089 P a g e 8
Section B Doctor s Section Doctor s Authority I, Title: First name(s): Last name: Of, Practice: In the state of: being a registered medical practitioner, have examined the above named patient and certify the following to be a true description of his/her condition: And I further certify that the patient was totally disabled from following his/her usual duties: From: / / To: / / (inclusive) Signed: Date: / / Qualifications: Suburb State: Postcode: Phone: ( ) Fax: ( ) Email: Please note: Australian Income Protection / Beazley Underwriting Pty Ltd is not liable for the costs associated in the completion of this section. Australian Income Protection Pty Ltd AFS No. 289089 P a g e 9
Section C Employer s Section Employee details: (Please print) Employee name: Employee number: Employed since: / / Date of injury or onset of sickness: / / Has been incapacitated since: / / To the best of your knowledge, describe where and how the incapacity occurred: Date employee is expected to resume duties: / / Employed type: Full-time Part-time Casual Contractor Work status: Employed Terminated Resigned Ceased work / / / / / / If he/she is fit to return to work on alternative/restricted duties, we are: Prepared to take employee back on alternative/restricted duties: Job description: Please advise the normal aspects of employee s role: LHMU/AWU enterprise agreement details: Is the employee, employed under the LHMU/AWU enterprise agreement? : When did you first sign up with the LHMU/AWU enterprise agreement?: / / Does the wage report provided, only apply to their employment under the LHMU/AWU enterprise agreement?: Has the employee salary sacrificed wages within those 12 months? : Do you agree to re credit all leave entitlements taken post the 21 day waiting period?: Australian Income Protection Pty Ltd AFS No. 289089 P a g e 10
Section C Employer s Section Wage Report To calculate the weekly benefit, we require a wage report showing a weekly breakdown for the 12 months preceding the date of incapacity. 12-month weekly wage report supplied: Has he/she salary sacrificed wages within those 12 months?: Average per week gross: $ During the period of incapacity he/she received: $ Normal Pay from / / to / / $ Sick Pay from / / to / / $ Workers Compensation from / / to / / $ Other from / / to / / If other, please specify: Workers Compensation Information This section MUST be completed even if the claim is not work related: Are you self insured for Workers Compensation: Name of current Workers Compensation Insurer: Policy number: Is the employee s condition work related: Is the employee on a current Workers Compensation claim: If yes, does your company have an agreement to top-up the Workers Compensation benefits: Manager s Details: Signature of Manager: Title: Last name: First name(s): Company name: Suburb State: Postcode: Phone: ( ) Fax: ( ) Mobile: Email: Date: / / Employer check list: Have all questions of Section C been completed? Have you supplied a wage report showing a weekly breakdown for the 12 months preceding the date of incapacity? Have you completed the Workers Compensation details? Australian Income Protection Pty Ltd AFS No. 289089 P a g e 11
THIRD PARTY AUTHORITY (optional complete only if required) If you require us to release or discuss information regarding your claim with another person, please complete and sign the following authority form and return it to our office with your fully completed claim form and any additional information required for the assessment of your claim. To be completed by the claimant Title: First name(s): Last name: I hereby authorise: Title: First name(s): Last name: Suburb State: Postcode: Phone: ( ) Mobile: Fax: ( ) Email: Date of birth: / / Relationship to claimant: to liaise with Australian Income Protection / Beazley Underwriting Pty Ltd in respect to my claim. If in future I no longer require the above mentioned person to act as a third party, I will notify Australian Income Protection / Beazley Underwriting Pty Ltd in writing. Signature of Claimant: Name of Claimant: Date: / / Australian Income Protection Pty Ltd AFS No. 289089 P a g e 12
Privacy Statement Personal information including your full name, address, contact details, age, gender as well as your health and financial information is information used to allow others to identify you. The Privacy Act 1988 also requires us to inform you that as an Insurer we may collect, store and disclose your personal and sensitive information in order to: Determine whether to issue a Policy; Determine the terms and conditions of Your Policy; Compile data; and Handle claims. We will act to protect your personal information in accordance with the National Privacy Principles (Australian Privacy Principles effective 12 March 2014) or an industry code and the protection of your personal information is a vital part of our service. We may disclose personal information to external organisations that help us provide you a service. These organisations are bound by confidentiality agreements and they may include overseas organisations. Sensitive information includes, amongst other things, information about an individual s health, membership of professional associations and criminal records. We may disclose personal information to third parties who we deal with in providing the relevant services and products. Personal information may be communicated to, released or obtained from: Brokers and agents who refer business to us; Any person acting on your behalf, including your advisor, solicitor or accountant, trustee, guardian or attorney; Any past or present Employer or Union Delegate or Representative; Medical Practitioners and Allied Medical Professionals (to verify or clarify health information you provided or as part of an independent medical examination); Claims investigators and reinsurers (so that any claim you make can be assessed and managed), insurance reference agencies; Other insurers (to verify or clarify other claims made e.g. workers compensation); Any Government Body or Complaint Tribunal or Ombudsman; and Organisations including overseas organisations, to whom we may outsource certain functions. In all circumstances where our contractors, agents and outsourced service providers become aware of personal information, confidentiality agreements apply. Personal information may only be used by our agents, contractors and outsourced service providers for our purpose. You are able to access your information held by Australian Income Protection a Beazley Company at any time. Information including reports may be provided under the following authority, other than in limited circumstances set out in the National Privacy Principles. Australian Income Protection a Beazley Company aims to ensure that your personal information is accurate and up-to-date and complete. Please contact us, if you would like to seek access to, or revise your personal information or feel that the information we currently have on record is incorrect or incomplete or believe that the privacy of your personal information at Australian Income Protection a Beazley Company has been interfered with. Your complaint will be managed and resolved through our internal dispute resolution process. We recommend that you retain a copy of this statement for your records. Australian Income Protection Pty Ltd AFS No. 289089 P a g e 13