• No results found

PERSONAL ACCIDENT INSURANCE CLAIM FORM AND PROCEDURE

N/A
N/A
Protected

Academic year: 2021

Share "PERSONAL ACCIDENT INSURANCE CLAIM FORM AND PROCEDURE"

Copied!
6
0
0

Loading.... (view fulltext now)

Full text

(1)

PERSONAL ACCIDENT INSURANCE

CLAIM FORM AND PROCEDURE

In order that your claim may be dealt with as quickly as possible, please ensure that you tick that you

have addressed all of the items below..

If you have not completed forms in full or have omitted to supply documents, you may experience

delays in the processing of your claim.

Please note; MEDICARE MEDICAL EXPENSES INCLUDING ANY GAP PAYMENT ARE NOT

CLAIMABLE UNDER THIS POLICY DUE TO FEDERAL HEALTH INSURANCE LEGISLATION.

If further information is required, you will be contacted directly by the Insurers, Chubb Insurance

Company of Australia Ltd. If you have any concerns with the claim process, the appointed broker for

the PAA http://www.polocrosse.org.au/, Marsh Pty Ltd ( 08 8385 3612) will be pleased to provide

assistance to you.

The Polocrosse Association of Australia website includes a downloadable brochure summarising the

benefits payable and claims process. Website address- www.polocrosse.org.au

Tick when completed

1. Fully complete pages 1, 2 and 3.

2. Ensure you sign the declaration in General Particulars on Page 3.

3. Ensure you sign the Authority to Give Information on Page 3.

4. Have your Doctor or treating physician complete and sign Pages 4 and 5.

5. Ensure you have an initial medical certificate, showing the likely date of

return to work.

If you remain incapacitated when the initial certificate expires, you will need to consult again with your

Doctor to obtain a continuing certificate. Please provide to your State Association Office or the Insurer

directly.

6. For weekly payments, you will need to supply evidence of earnings from

your own personal exertion, not including investments etc, for the 12 months prior to your

injury.

7. If you wish to be paid weekly benefits by Electronic Funds Transfer,

complete the Bank Details form, Page 4.

8. Send completed form and supporting documentation to your State

Polocrosse Association Office as soon as possible when your membership

will be verified.

This cover sheet has been prepared to assist members provide the information which is important to process

any accident insurance claim as quickly as possible.

(2)

CHUBB Insurance Company of Australia Limited – Accident & Health Specialist Claims Division Phone: 1300 795 779 Fax: 1300 795 879 Post: PO Box 20336, World Square Post Office,

NSW Australia 2002

E-mail:

aus.ahclaims@chubb.com 1

C H U B B

CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED ACN 003 710 647

AFS 239778

Polocrosse Association of Australia Inc.

Personal Accident Claim Form

(This Issue of this Form is not an Admission of Liability by Chubb Insurance Company of Australia Limited)

CLAIM No

___________________ ___________________

POLICY No

___93102555________ ________

___________________

MEMBERSHIP No ___________________ BRANCH: Sydney

Chubb Insurance Company of Australia Limited

ADDRESS: PO Box 20336 World Square Post Office NSW 2002

Phone 1300 795 779 Fax 1300 795 879 Email aus.ahclaims@chubb.com

Notice in writing must be sent to the company within 30 days from its occurrence, or the claim may not be recognised. Please complete this form and return it to Chubb Insurance within that time period.

Important Note: The Section headed Medical Certificate is required to be completed by the attending Physician.

Surname _______________________________ First Name ________________________ Title e.g. Mrs ___________________ Address ________________________________________________________________________________________________ ____________________________________________________________________ Postcode ___________________________ Email Address __________________________________________________________________________________________ Date of Birth _____/___/___ Sex (M/F) ________________ Marital Status ______________________ Dependants ___________ Place of Birth _____________________________ Occupation _____________________________________________________ Telephone (Home) ____________________ (Business) ____________________ (Mobile) _______________________________ Employer’s Name _______________________________________ Telephone No _____________________________________ Address _____________________________________________________________________ Postcode ___________________ Were you employed at the time of suffering the accident? Yes No

If No, provide full details: ___________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Was your employment Full time Part time Temporary Length of Service _______________

SECTION A – ACCIDENT

Location where accident occurred ____________________________________________________________________________ Date of Accident _____/____/____ Time ________________ am/pm

What were you doing? _____________________________________________________________________________________ _______________________________________________________________________________________________________ How did it occur? _________________________________________________________________________________________ _______________________________________________________________________________________________________ Nature and extent of injuries ________________________________________________________________________________ Have you ever previously suffered from this type or a similar type of injury? Yes No

If Yes, provide full details: __________________________________________________________________________________ _______________________________________________________________________________________________________

(3)

CHUBB Insurance Company of Australia Limited – Accident & Health Specialist Claims Division Phone: 1300 795 779 Fax: 1300 795 879 Post: PO Box 20336, World Square Post Office,

NSW Australia 2002

E-mail:

aus.ahclaims@chubb.com 2

PERIOD OFF WORK

Give date and time of your first medical consultation for this Accident/Sickness Date _____/_____/_______ Time ______________ am/pm

On what date did you last work? _____/_____/_______

Have you been able, since the Accident/Sickness occurred, to attend in any way to your business/employment or any portion of it?

Yes No

If Yes, provide full details:

________________________________________________________________________________________________________ __________________________________________________________________________________________________________ ______________________________________________________________________________________________________

Have you been able to engage in any other occupation following your Accident/Sickness? Yes No If Yes, provide full details:

________________________________________________________________________________________________________ __________________________________________________________________________________________________________ ______________________________________________________________________________________________________

I am now disabled Wholly Partially Not at all On what date did you return to work? ____/____/____

If still disabled, state how much longer disability is likely to continue ______________ weeks / months / permanent

Name and Address of Medical Practitioner who attended this condition:

Name ______________________________ Address ____________________________________________________________ ___________________________________________________________________ Postcode ____________________________

Name and Address of your regular Medical Practitioner:

Name ______________________________ Address ____________________________________________________________ ___________________________________________________________________ Postcode ____________________________

PREVIOUS MEDICAL HISTORY

What other medical or surgical advice, treatment or attention have you received during the past five years? (Give dates, nature of injury or sickness and names and addresses of all doctors, hospitals and clinics). Please answer fully – dashes are not acceptable.

Date Nature of Injury or

Sickness Names Address

(4)

CHUBB Insurance Company of Australia Limited – Accident & Health Specialist Claims Division Phone: 1300 795 779 Fax: 1300 795 879 Post: PO Box 20336, World Square Post Office,

NSW Australia 2002

E-mail:

aus.ahclaims@chubb.com 3

GENERAL PARTICULARS

Are you insured elsewhere for Accident or Sickness? __________ If Yes, provide Name and Address of Insurer

Name ______________________________ Address _____________________________________________________________ ________________________________________________________________________ Postcode _______________________ Do you hold Private Health Insurance? Yes No

If Yes, which Insurer _______________________________________________________________________________________

Have you lodged a claim under Work Cover / Workers Compensation / Compulsory Third Party insurance or are you eligible to lodge a claim under Work Cover / Workers Compensation / Compulsory Third Party insurance?

Yes No

If Yes, provide Name and Address of Insurer

Name ______________________________ Address _____________________________________________________________ ________________________________________________________________________ Postcode _______________________ Claim Number ______________________ Status of Claim _____________________________________________________

Are you entitled to sick leave? Yes No If Yes, please advise number of days or

Period you have received sick leave From ____/____/____ To ____/____/____

If you are claiming weekly benefits

Please provide your gross basic salary (excluding bonuses, commission, over-time payments and other allowances) averaged over the calendar year immediately preceding injury/sickness.

Note: A copy of your last three (3) payslips prior to date of injury / illness or tax statement for the last financial year will also be required.

AUTHORITY TO GIVE INFORMATION

(To be signed by the claimant)

I hereby authorise any doctor or medical attendant who has treated me or examined me or any person or firm who employs or has employed me to give the underwriter such information as it may require regarding any illness and/or injury to me or my physical or mental condition or prognosis, or my employment, to assist in the proof and settlement of my claim. A photocopy or xerography copy of this authority can be acted upon as if it were original.

Signature __________________________________________________________________________ Date ____/____/_____ Note: The issue or acceptance of this form is not to be construed as an admission of liability on the part of Chubb Insurance Company of Australia Ltd.

DECLARATION

(To be signed by the claimant)

I hereby declare that I am suffering or have suffered from the injury or sickness above named and warrant the truth of the foregoing particulars in every respect, and I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my right to compensation could be forfeited.

Signature of Claimant ____________________________________ Address _________________________________________ ___________________________________________________________________________ Postcode ___________________ Date ____/_____/____

(5)

CHUBB Insurance Company of Australia Limited – Accident & Health Specialist Claims Division Phone: 1300 795 779 Fax: 1300 795 879 Post: PO Box 20336, World Square Post Office,

NSW Australia 2002

E-mail:

aus.ahclaims@chubb.com 4

PAYMENT DETAILS

Electronic Funds Transfer: Yes No

Account Name: (Mr,Mrs,Ms,Miss)__________________________________________________________ Account Number: ________________________________________________________________________ Bank Name: ________________________________________________________________________ Bank Address: ________________________________________________________________________ BSB Number: ________________________________________________________________________

Swift Code

(For International Transfers) _______________________________________________________________________

Cheque: Yes No

Name of Payee: (Mr,Mrs,Ms,Miss) ____________________________________________________________ Street Address: __________________________________________________________________________ Suburb/Town: __________________________________________________________________________ State: _______________________ Post Code: __________________________________

MEDICAL CERTIFICATE / CERTIFICATE OF ATTENDING PHYSICIAN

(To be completed by the attending Physician)

The claimant must obtain, at their own expense, the completion of this certificate from a duly qualified and registered medical practitioner. In the event of the medical practitioner being unable to answer from his own personal knowledge any of the following questions, he is requested to state so.

Furnished in connection with the disability of:

Name of Patient ______________________________ Address_____________________________________________________ _________________________________________________________________________ Postcode______________________ Are you the patient’s regular physician? Yes No

If Yes, how long have you known the patient? Years __________________ Months ______________________________ Diagnosis of Illness / Injury ________________________________________________________________________________ Complications ___________________________________________________________________________________________ Has the patient previously suffered from the same or similar injury/sickness? Yes No

If yes, provide the date and diagnosis ________________________________________________________________________ _______________________________________________________________________________ Date ___/____/____ Date of first consultation for this condition Date ____/____/____

How long has this condition, in your opinion, been in existence whether treated for same or not?

_______________________________________________________________________________________________________ Present Condition ________________________________________________________________________________________ Prognosis ______________________________________________________________________________________________ Nature of Operation (if any) ________________________________________________________________________________ _______________________________________________________________________________________________________ Name of Physicians who previously treated patient for above condition

Name _________________________________________ Name___________________________________________________ Are the patient’s symptoms -

due exclusively to the accident, or traceable to disease, infirmity or any other cause?

(6)

CHUBB Insurance Company of Australia Limited – Accident & Health Specialist Claims Division Phone: 1300 795 779 Fax: 1300 795 879 Post: PO Box 20336, World Square Post Office,

NSW Australia 2002

E-mail:

aus.ahclaims@chubb.com 5

Is there anything in the patient’s medical history which may have contributed, directly or indirectly, to the injury/illness or which may be likely to retard the patient’s recovery?_______________________________________________________________________ _______________________________________________________________________________________________________ Is patient still under your care for this condition? Yes No

If not, on what date did you release patient to perform regular duties Date _____/_____/_____ Dates totally unfit for work (unable to perform specific parts of the patient’s occupation): From ____/____/____ To ____/____/____ (Both dates inclusive)

Dates partially unfit for work (unable to perform specific parts of the patient’s occupation): From ____/____/____ To ____/____/____ (Both dates inclusive)

If uncertain, please estimate: Totally Unfit to (date) ____/____/____ Partially Unfit to (Date) ____/____/____

Have you any reason to suppose that the patient was under the influence of Intoxicants or drugs at the time of the accident? Yes No

If hospitalised, give dates: From ____/____/____ To ____/____/____

Name of Hospital ________________________________________________________________________________________ Give dates patient was totally disabled: From ____/____/____ To ____/____/____

In your opinion, probable further disability should not exceed __________ weeks/months From ____/____/____ Name of Physician _______________________________________ Address _________________________________________ _____________________________________________________________________ Postcode _________________________ Phone Number ______________________________________ Qualifications _________________________________________ Signature ____________________________________________________________________ Date ____/_____/_____

STATE POLOCROSSE ASSOCIATION ADMINISTRATOR CERTIFICATION

THIS PAGE OF THE CLAIM FORM NEEDS TO BE COMPLETED BY A STATE ASSOCIATION ADMINISTRATION OFFICER

1. Name of Injured Person ________________________________was injured as stated whilst participating in________________

________________________________________________________Event at the Club.

2. Name of Home Club?_________________________________________________________________State _________ 3. Address of Club? _________________________________

4. On what date did the injured person sustain the injury? _______/________/_________

5. Was the activity in which the injured person of the organisation was participating; at the time of injury, an officially authorised and sanctioned activity of the insured organisation? Yes No

Declaration: I, ____________________________________ am the _______________________________________________ (full name) (title of office bearer)

declare that the information provided in this certification is true, correct and completed to the best of my knowledge and ability.

Signed_________________________________________ Dated:_______________________

Melanie Kelly State Executive Officer

References

Related documents

The Customer agrees that under the RTGS/ NEFT facility, there may be a risk of non-payment in the Account of Customer on the day of the credit of Payments due to change in the

Permanent Total Disablement / Permanent Partial Disablement / Temporary Total Disablement: Claim Form duly filled & signed Claim Intimation.

I have been informed of my statutory rights under the Access to Medical Reports Act 1988 as explained above and in connection with my insurance claim I hereby consent to Aviva

• The information collected by this Notice of Accident Claim Form, and throughout the course of your claim, may be disclosed in accordance with the Motor Accident Insurance Act 1994

Personal Accident Insurance claim Complete and send to: HCF Life Insurance Company Pty Ltd GPO Box 4445, Sydney, NSW 2001 Please note that we also require the attached

I authorise any hospital, physician or other person who has attended me, or any employer, to give QBE Insurance (Australia) Limited or its representative any or all information

By signing this form I agree that Corporate Services Network (including the Insurers they represent and claims management services) and third parties such as my insurance

If you choose not to provide your personal information and/or choose not to consent and / or withdraw your consent to the disclosure of your personal information at any stage, we