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ACCIDENT AND ILLNESS CLAIM FORM

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ACCIDENT AND ILLNESS CLAIM FORM Powered By Docstoc
					                                                                        ACE Insurance Limited                                                         0800 300 401 Tel
                                                                        CU1-3, Shed 24                                                                09 303 1909 Fax
                                                                        Princes Wharf
                                                                        Auckland 1010
                                                                        PO Box 734, Auckland 1140
                                                                        New Zealand


ACCIDENT AND ILLNESS CLAIM FORM
Name of Insured Company:                       ......................................................................................................................................

Name of Claimant: .........................................................................................                 Date of Birth:                     /              /

Residential Address: ...................................................................................................................................................

Home Ph:           .........................................................................    Business Ph: ...............................................................

Email: .........................................................................................................................................................................

Policy/Account Number:


Please provide full copies of all medical reports, X-ray & scan results, Admission & Discharge summaries
and any post-operative records from the hospital(s). If applicable please also supply any ACC reports and
payment details.



                      ACCIDENT PARTICULARS                                                                             ILLNESS PARTICULARS

Date of accident ................................ at .............am/pm                        Date of illness ................................... at ............ am/pm

How and where did the accident happen? ........................                                Nature of illness ...............................................................

.........................................................................................      .........................................................................................

.........................................................................................      .........................................................................................

.........................................................................................      .........................................................................................

Describe injuries ..............................................................               .........................................................................................

.........................................................................................      .........................................................................................

.........................................................................................      .........................................................................................

Have you suffered from this injury before?                                                     Date symptoms first appeared .........................................
YES              NO
                                                                                               .........................................................................................
If “Yes”, state when ..........................................................
                                                                                               Have you suffered from this illness before?
.........................................................................................      YES             NO

Name and address of any witness to your accident ..........                                    If “Yes”, state when .........................................................

.........................................................................................      .........................................................................................

.........................................................................................      .........................................................................................



Name and address of General Practitioner: .................................................................................................................

.................................................................................................. Ph: ..........................................................................

Have you been hospitalised for this condition?                                                                  YES                            NO

Date Admitted:                            /               /                           at ....................am/pm

Date Discharged:                          /               /                           at ....................am/pm

Name of Hospital: ........................................................................................................................................................

How long were you confined at home by a Doctor?                                    From:               /           /                     To:            /            /

If surgery was performed, describe procedure: ............................................................................................................

.....................................................................................................................................................................................

Name of Surgeon: ........................................................................................... Ph: .....................................................
EMPLOYMENT DETAILS

Occupation: .................................................................................................................................................................

Employer/Business Name: ...........................................................................................................................................

Address: ......................................................................................................................................................................

Telephone: .................................................... Email: ..................................................................................................

Duties performed in usual occupation: .........................................................................................................................

.....................................................................................................................................................................................

Average hours worked per week: .................................................................................................................................

Period of Employment:                                                               From:             /           /                     To:            /            /

What date did you cease all forms of work?                                                            /           /

If you have recommenced work, date you did so                                                         /           /

Is your position of employment available to you upon recovery?                                                 YES                            NO


TO BE COMPLETED IF SELF-EMPLOYED

Please submit relevant documentation to validate earnings, 12 months prior to the Injury/Illness.

What are your average weekly earnings, net of expenses, before tax? $.....................................................................

Do you operate as a Limited Liability Company?                                                                 YES                            NO

Do you or your Company pay an ACC Levy?                                                                        YES                            NO

Business Trading Name: ................................................................................. Ph: .....................................................

Business Address: .......................................................................................................................................................

Date the business commenced trading:                                                                  /           /

Accountants Details

Name: ............................................................................................................. Ph: .....................................................

Address: ......................................................................................................................................................................


EMPLOYER/PAYMASTER TO COMPLETE (If Insured is a wage earner)

I hereby certify that ................................................................ has been unable to attend to his/her usual occupation
with the Company as a result of an Injury or Injuries/Illness suffered whilst ..................................................................

........................................................................................................................................ on                /            /

He/She has been incapacitated since                                /            /              and is expected to resume or did resume duties on
       /      /        in part or in full.

Please provide details: .................................................................................................................................................

.....................................................................................................................................................................................

Will His/Her position (prior to the event) still be available when He/She is fit to resume His/Her duties?
                                                                            YES                 NO

If not please explain: ....................................................................................................................................................

.....................................................................................................................................................................................

What was His/Her average weekly salary (excluding bonuses, commissions, overtime payments and other
allowances) for the 12 month period prior to the injury or illness? $.............................................................. per week.
During the period of incapacity he/she received:

Normal Pay - $ ..................................                     from               /            /              to              /           /

Sick Pay -           $ ..................................             from               /            /              to              /           /

ACC -                $ ..................................             from               /            /              to              /           /

Other (please specify): .................................................................................................................................................

                     $ ..................................             from               /            /              to              /           /

He/She has been employed at the Company since:                                           /            /

Name of Company:.......................................................................................................................................................

Name of Employer/Paymaster: ....................................................................... Ph: .....................................................

Email: ..........................................................................................................................................................................

Signature: .................................................................................................................... Date                      /            /


OTHER INSURANCE

List all other insurance policies that you have which provide cover for this event: ........................................................

.....................................................................................................................................................................................

.....................................................................................................................................................................................

Have you lodged a claim with Accident Compensation Corporation?                                                YES                            NO

If “yes” please provide copies of all related documents.


SETTLEMENT DETAILS

Please indicate whether you would prefer to receive your payment by:

Cheque

Direct Debit

Payee Name: ...............................................................................................................................................................

Payment by direct credit to a NZ bank account. Please complete bank details below:

Bank Account Number:




Bank: .................................................................................. Branch: ..........................................................................

Account Name: ............................................................................................................................................................

Email address for Broker/Payee: ..................................................................................................................................
PRIVACY CONSENT & DECLARATION

Privacy

ACE Insurance Limited (“ACE”) collects, uses and retains your personal information only in accordance with the
principles in the Privacy Act 1993. A copy of our Privacy Statement, which expands upon our privacy obligations and
provides further information on your rights to access your personal information held by us is available on our website
or by contacting our Privacy Officer on +64 (9) 3771459.

Your personal information will be used by ACE, or any third party that ACE provides the information to, for the
purpose of assessing your claim or your entitlement to benefits and, if the claim is accepted, for administration of the
claim and for planning, product development and research purposes.

Your personal information includes:

(a)         any information provided in relation to your claim;

(b)         any information that is health information or sensitive information;

(c)         any other personal information that you may provide to ACE or its third party contractors;

(d)         any information relating to the insurance policy on your life, including terms and conditions and claims
            history;

(e)         details of your employment including position, period of employment, remuneration, hours worked and
            duties performed; and

(f)         any other information relating to your income and solvency.

To process your claim ACE may need to collect your personal information from third parties such as your insurance
broker, claims reference services, government organisations (for example social security agencies or taxation
offices), any forensic accountant retained by ACE, your employers (past and present), your accountant and any
businesses which provide information about the commercial activities of persons or, if you are, or have been,
bankrupt the trustee of your estate (the “Parties”). You agree that the Parties may disclose your personal information
to ACE.

ACE may disclose your personal information, including health and sensitive information, to third parties, including
contractors and contracted service providers engaged by us to deliver our services (such as assessors), other
companies in the ACE group, other insurers, our reinsurers, and government agencies (where we are compelled to
by law). These third parties may be located outside New Zealand. ACE may also disclose your personal information
to witnesses in respect to your claim.

You agree to us using and disclosing your personal information pursuant to ACE’s Privacy Statement and this Claim
Privacy Consent. In the event of any conflict between the documents, this Claims Privacy Consent shall be
determinative. This consent remains valid unless you alter or revoke it by giving written notice to our privacy officer.

If you do not consent to the terms of this Claims Privacy Consent or revoke your consent, ACE may not be able to
process or assess your claim.


Claimant Declaration

I declare that to the best of my knowledge, the above are true statements of fact and that I have not withheld any
information relevant to this claim.

I hereby request and authorise any hospital, doctor, or other person who has attended or examined me or any
member of my family to furnish to ACE Insurance Limited or their representative any and all information concerning
any illness or injury suffered, medical history, consultations, prescriptions, or treatments including X-ray plates and
copies of all hospital or medical records, that they may be included as a part of the proofs of loss submitted with this
claim. A photocopy of this authorisation shall be considered as effective and valid as the original.

I authorise the disclosure to ACE Insurance Limited of personal information held by any other person or organisation
regarding or affecting this claim and authorise ACE Insurance Limited to release to any other person or organisation
information regarding or affecting this claim.


Date at       ...................................................   this   ..................... day of ........................................ 20 ..........

Signature     ................................................................ Witness Signature ...............................................................

Name          ................................................................ Name                     ...............................................................

Address       ................................................................ Address                  ...............................................................

				
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