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CLAIM FORM CONTRACTORS INJURY SICKNESS

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CLAIM FORM CONTRACTORS INJURY SICKNESS Powered By Docstoc
					                                                  CLAIM FORM:
                  INSURANCE SOLUTIONS
                                                 CONTRACTORS
                                               INJURY & SICKNESS

      For further information contact ATC Insurance Solutions on 1800 994 694.

                                                          INSTRUCTIONS



    1. 	 YOU	fully	complete	Section	A	of	the	claim	form	including	either	the	Injury	statement	or	
                                      the	Sickness	statement.



    2. 	                       Your	DOCTOR	fully	completes	Section	B	of	the	claim	form.



    3.              Attach	a	copy	of	your		returned	Income Tax Assessment	
     (As	completed	by	the	ATO)	for	the	most	recent	financial	year	or	alternatively	a	copy	of	your	
                   most	recent	Individual	Tax	Return	(As	submitted	to	the	ATO).
      In	the	event	that	these	documents	are	not	available,	you	may	submit	a	(Certified)	letter	from	your	Accountant	which	stipulates	your	
                (Gross)	taxable	income	less	business	expenses	for	the	12	calendar	months	preceding	the	date	of	injury/sickness.




    4.		                   Enclose	a	copy	of	the	radiological	report	for	a	broken	bone	claim



    5. 	              Please	ensure	all	the	details	are	correct	and	that	each	section	is	signed.



    6. 	                                               Send	the	claim	form	to:
                                                     ATC Insurance Solutions
                                                    Level 2, 499 St Kilda Road
                                                       Melbourne Vic 3004

   Please note if each Section of the claim form isn’t completed correctly and signed it will delay your claim.



                  ATC	Insurance	Solutions	Pty	Ltd	(ABN	25	121	360	978	AFSL	305802)	is	acting	under	the	authority	
               of	the	insurer	and	will	be	dealing	with	this	insurance	claim	as	agent	of	the	insurer	and	not	the	insured


                                                        ATC	Insurance	Solutions	Pty	Ltd		
                                                Level	2,	499	St	Kilda	Road,	Melbourne	Vic	3004	
                                               Telephone:	03	9258	1777	Facsimile:	03	9867	5540		
                                               Email:	info@atcis.com.au	Web:	www.atcis.com.au

25.11.2009                                                                                                                                   1
 Section A - To be completed by the Insured
 All questions must be completed or claim form will be returned and assessment of your claim will be delayed

 Surname:.......................................................................Given	Names:	.....................................................................................................................Title:	................................... 	
 Sex:		Male	 			Female	 	Date	of	Birth:	...........	/...........	/.............................	Height:	.............................................cm				Weight	:	.................................................... kg



 Street	Address:	.......................................................................................................................................................................................................................................................... 	
 Suburb:........	..............................................................................................................................................State:	..........................................Postcode:	........................................ 	
 Postal	Address:	.......................................................................................................................................................................................................................................................... 	
 Suburb:	......................................................................................................................................................State:	..........................................Postcode:	........................................ 	
 Home	Telephone:....................................................................Mobile	No:	.......................................................................Work	No:	................................................................. 	
 Email:	............................................................................................................................................................................................................................................................................

 	
 Name	of	Employer:	..................................................................................................................................................................................................................................................
 Site	Name	&	Address:	............................................................................................................................................................................................................................................. 	
 ........................................................................................................................................................................................................................................................................................ 	
 Suburb:	......................................................................................................................................................State:	..........................................Postcode:	........................................ 	
 	
 Please	list	your	usual	duties	and	percentage	of	time	spent	on	each	task:

     Tasks                                                                                                                                                                                                                        %	Time	spent




 Q	My	average	weekly	income	(before	personal	deductions	and	income	tax)	received	by	me	which	was	earned	from	personal	exertion	during	
 the	twelve	(12)	month	period	immediately	preceeding	disablement	was	$		.....................................................	

 Attach	a	copy	of	your		returned	Income Tax Assessment	(As	completed	by	the	ATO)	for	the	most	recent	financial	year	or	alternatively	a	copy	
 of	your	most	recent	Individual	Tax	Return	(As	submitted	to	the	ATO).
 In	the	event	that	these	documents	are	not	available,	you	may	submit	a	(Certified)	letter	from	your	Accountant	which	stipulates	your	(Gross)	
 taxable	income	less	business	expenses	for	the	12	calendar	months	preceding	the	date	of	injury/sickness.



 Electronic Funds Transfer
 If	ATC	Insurance	Solutions	approves	your	claim	and	you	wish	to	have	your	claim	benefits	transferred	directly	into	your	bank	account,	
 please	complete	the	following	details:



 Bank	Name:		.......................................................................................... Bank	Branch:		......................................................................................................................................................	
 Account	Name:		................................................................................... BSB:		......................./..........................	Account	No:			........................................................................................	




25.11.2009                                                                                                                                                                                                                                                                             2
 Injury Statement (Section A continued)
 Please only complete this section if your claim is as a result of an Injury (if your claim is for Sickness please proceed to the next page)
 Date	of	Injury:	...........	/...........	/.............................		Time	of	Injury:	.................................................................................am/pm
 Q	What	is	the	nature	of	your	Injury(ies).	e.g	fracture,	burn,	degenerative	etc:
 ........................................................................................................................................................................................................................................................................................
 Q	What	part	of	the	body	does	it	relate	to.	e.g	leg,	face,	etc
 ........................................................................................................................................................................................................................................................................................
 Q	What	specific	event	occurred	to	cause	the	Injury(ies).
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	Where	were	you	at	the	time	of	the	Injury.	Address	if	applicable:
 ........................................................................................................................................................................................................................................................................................
 Q	Were	there	any	witnesses	to	this	Injury.	If	so,	please	provide	name(s)	and	contact	detail(s):
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	What	date	were	you	first	unable	to	attend	your	usual	duties	as	a	result	of	this	Injury:	...........	/...........	/.............................	
 Q	What	date	did	you	first	consult	a	doctor	for	this	Injury:	...........	/...........	/.............................	
 Q	Did	the	Injury	occur	during	the	course	of	your	usual	occupation:		 		Yes			 		No	
 Q	Have	you	ever	had	a	similar	condition	in	the	past?	If	Yes,	please	give	details:		 		Yes			 		No	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	If	you	answered	Yes,	please	explain	if	there	is	any	relation	between	the	previous	Injury	and	this	Injury	you	are	claiming	for	now?
 Or	if	not,	why	not:	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	How	long	do	you	anticipate	you	will	be	away	from	work	as	a	result	of	this	injury:	.......................................................days/weeks
 Q	If	you	have	already	returned	to	work,	please	specify	the	date:	...........	/...........	/.............................	
 Q	Please	list	all	your	treating	medical	practitioners	over	the	past	five	years.

   Doctor’s	Name                                                                         Period	of	Attendance                                     Speciality                               Phone                                           Fax
                                                                                           From                               To




 Please	list	all	the	doctors	you	have	consulted	in	relation	to	this	injury	and	the	dates	of	consultation	if	known.

   Doctor’s	Name                                                                         Period	of	Attendance                                     Speciality                               Phone                                           Fax
                                                                                           From                               To




 Q	Please	list	what	usual	duties	you	are	still	able	to	perform	as	a	result	of	this	Injury
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	Please	list	what	usual	duties	you	are	unable	to	perform	as	a	result	of	this	Injury
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	What	is	your	current	treatment	program	as	prescribed	by	your	treating	doctor(s)	e.g.	medication,	surgery,		physio,	exercise,	etc:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................

25.11.2009                                                                                                                                                                                                                                                                             3
 Sickness Statement– (Section A continued) Please only complete this section if your claim is for a Sickness
 Q What	Sickness	are	you	suffering	from	resulting	in	you	claiming	under	this	policy?
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	On	what	date	did	you	first	become	aware	of	this	condition:	...........	/...........	/.............................	
 Q	On	what	date	did	you	first	seek	treatment	from	a	doctor	in	relation	to	this	condition:	...........	/...........	/.............................	
 Q	On	what	date	were	you	first	unable	to	attend	your	usual	duties	as	a	result	of	this	condition:	...........	/...........	/.............................	
 Q	Have	you	ever	had	a	similar	condition	in	the	past?	If	so,	please	specify	the	dates	you	were	being	treated	for	this	condition:

   Doctor’s	Name                                                                         Period	of	Attendance                                     Speciality                               Phone                                           Fax
                                                                                           From                               To




 Q	In	your	own	words	please	explain	if	there	is	or	there	is	not	any	relationship	between	the	previous	condition	(if	there	was	one)	and	the	
 condition	you	are	claiming	for	now:	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	How	long	do	you	anticipate	you	will	be	away	from	work	as	a	result	of	this	condition:		.......................	days/weeks
 Q	If	you	have	already	returned	to	work,	please	specify	the	date:		...........	/...........	/..............................	
 Q	Have	your	treating	doctors	at	any	time	advised	you	to	cease	treatment	for	this	sickness:			 		Yes			 		No
 Q	Please	list	all	your	treating	medical	practitioners	over	the	past	five	years.

   Doctor’s	Name                                                                         Period	of	Attendance                                     Speciality                               Phone                                           Fax
                                                                                           From                               To




 Q	Please	list	the	doctors	you	have	consulted	in	RELATION	TO	THIS	SICKNESS	and	the	dates	of	consultation	if	known.

   Doctor’s	Name                                                                         Period	of	Attendance                                     Speciality                               Phone                                           Fax
                                                                                           From                               To




 Q		Please	list	what	usual	duties	you	are	still	able	to	perform	as	a	result	of	this	condition:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	Please	list	what	usual	duties	you	are	unable	to	perform	as	a	result	of	this	condition:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	What	is	your	current	treatment	program	as	prescribed	by	your	treating	doctor(s)?	e.g.	medication,	surgery,	physio,	exercise	etc:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
25.11.2009                                                                                                                                                                                                                                                                             4
 Other Insurance Cover (Section A continued)
 Q	In	respect	of	this	Injury	or	Sickness	are	you	receiving	or	planning	to	lodge	a	claim	against:
 1.			Motor	Accident	Compensation	benefi:				..............................................................................................................	 		Yes			 		No
 2.			Worker’s	Compensation	Benefit	(Workcover)				..................................................................................................	 		Yes			 		No
 3.			Sick	Leave	benefits:	.......................................................................................................................................................	 		Yes			 		No
 4.			Centerlink	and/or	Government	Disability	Benefits	...........................................................................................	 		Yes			 		No
 5.			Private	Health	Fund		.....................................................................................................................................................	 		Yes			 		No
 6.			Any	other	insurance	policy	........................................................................................................................................	 		Yes			 		No
 Q	If	you	have	answered	Yes	to	any	of	the	above	please	give	details	below	and	number	against	each	(e.g.;	1,	2,	3)
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................


 Privacy Act
 ATC	Insurance	Solutions	is	bound	by	the	requirements	of	the	Privacy	Act	1988,	which	sets	out	standards	on	the	collection,	use,	disclosure	
 and	handling	of	personal	information.	
 ATC	Insurance	Solutions	collects	personal	information	from	you	for	the	purpose	of	providing	you	with	insurance	products,	services	and	
 processing	and	assessing	claims.
 Your	personal	information	is	treated	with	care.	ATC	Insurance	Solutions	will	not	release	your	personal	information	to	anyone	else	other	than	
 the	insurer,	its	related	entities	or	as	permitted	or	required	by	law.	
 If	you	make	a	claim	under	this	insurance,	ATC	Insurance	Solutions	may	disclose	information	to	(and/or	collect	additional	information	about	
 you	from)	claims	investigators,	claims	managers,	assessors,	lawyers,	medical	practitioners	and	health	workers,	and	federal	or	state	regulatory	
 authorities,	including	Medicare	Australia	and	Centrelink.	
 You	have	the	right	to	seek	access	to	your	personal	information	and	to	correct	it	at	any	time.
 If	you	require	further	information	or	would	like	a	copy	of	ATC	Insurance	Solutions’s	Privacy	Policy	please	contact	our	Privacy	Officer	on	
 (03)	9258	1777	or	write	to	ATC	Insurance	Solutions	at	the	address	given	above.	A	copy	of	our	Privacy	Policy	can	also	be	obtained	from	our	
 website.
 Medical Authority
 I	hereby	authorise	any	hospital,	physician,	insurer,	Medicare	Australia,	my	employer	or	other	person	who	has	attended	me	to	furnish	to	ATC	
 Insurance	Solutions	Pty	Ltd	or	its	representatives	any	and	all	information	with	respect	to	any	sickness	or	injury,	medical	history,	consultation,	
 prescription	or	treatment	and	copies	of	all	medical	records.		I	also	authorise	any	and	all	information	regarding	Worker’s	Compensation	claims	
 or	claims	with	any	other	insurer	to	be	released	to	ATC	Insurance	Solutions	Pty	Ltd.		I	agree	that	a	photocopy	or	fax	copy	of	this	authorisation	
 shall	be	considered	as	effective	and	valid	as	the	original.
 Declaration
 I do solemnly and sincerely declare that the above particulars are true and correct in every detail and I agree that if I have made, or
 in any further declaration in respect of the claim make, any false or fraudulent statements or suppress, conceal or falsely state any
 material fact whatsoever the Policy shall be void and all rights to recovery thereunder or in respect of past, current or future claims
 shall be forfeited.
 Q		I	further	declare	that	the	claim	I	am	making	for	Injury	&	Sickness	benefits	is	not	covered	by	Workers	Compensation.


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


 Name	(print)		.........................................................................................................................................................................




25.11.2009                                                                                                                                                                                                                                                                             5
 Section B – Doctor’s Statement – To be completed by Your Treating Medical Practitioner
 All certificates and evidence required by us shall be furnished as required at the Insured Person’s expense.

 Patient’s	Full	Name:	...............................................................................................................	..............................................Date	of	Birth:	...........	/...........	/.............................	
 Sex:		Male	 			Female	 				Patient’s	Height:	............................................cm				Weight	:	............................................kg

 Q	Date	of	injury	(if	applicable):	...........	/...........	/.............................	
 Q	What	is	your	diagnosis	of	the	patient’s	condition:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................

 Q	What	was	the	cause	of	this	condition:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	Do	you	consider	this	condition	to	be	as	a	result	of	an	injury		 		or	sickness/illness		 		
 Please	provide	reasoning	for	your	response:	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	To	your	knowledge,	on	what	date	did	the	patient	first	seek	treatment,	or	advice	for	treatment,	from	a	registered	and	legally	qualified	
 medical	practitioner	in	relation	to	this	condition:		...........	/...........	/..............................
 Q	On	what	date	did	you	first	consult	the	patient	in	relation	to	this	condition	(if	different	from	above):		...........	/...........	/..............................
 Q	Has	the	patient	ever	suffered	from	a	similar	condition	in	the	past,	and	if	so,	does	it	relate	to	this	current	condition
 (if	so,	please	also	state	if	you	treated	the	patient):		
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 Q	How	long	has	the	patient	been	attending	you/your	practice?		.........................	months	...........................years
 Q	What	is	the	patient’s	current	treatment	program:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	Have	you	at	any	time	advised	the	patient	that	they	can	cease	all	treatment	for	this	condition:			 		Yes			 		No
 Q	Please	provide	any	relevant	medical	history	that	may	assist	us	with	this	claim:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
25.11.2009                                                                                                                                                                                                                                                                             6
 (Section B continued)	
 Q	What	investigations	have	been	undertaken	in	determining	a	diagnosis:
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	Please	supply	the	names,	specialties	and	contact	details	of	medical	practitioners	that	the	patient	has	been	referred	to	for	this	condition?

     Doctor’s	Name                                              Period	of	Attendance                                     Speciality                               Phone                                                      Fax
                                                                  From                               To




 Q	Do	you	consider	the	patient	to	be/has	been	wholly	and	continually	prevented	from	engaging	in	his/her	usual	occupation	as	a	result	of	this	
 condition?			 		Yes			 		No		

 	If	Yes,	for	what	period:	.................	/.............	/..............................		to	................	/.............	/..............................
 Q	If	you	answered	No,	has	there	been,	or	will	there	be,	any	period	of	disablement	as	a	result	of		this	condition?	
 Q		If	so,	please	specify	the	dates	and	reasons.
 From:		..............	/.............	/..............................		to		..............	/.............	/..............................
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................ 	
 ........................................................................................................................................................................................................................................................................................
 Q	Estimated	date	of	return	to	work:	...........	/...........	/..............................
 Q	In	your	opinion,	is	the	condition	related	either	to	work	or	to	a	motor	accident	compensation	claim			 		Yes			 		No
 Q	If	the	injury	is	a	broken	bone,	please	state	the	nature	and	extent	of	the	break/fracture	and	attach	a	copy	of	the	radiological	report	(please	
 advise	specifically	whether	it	is	a	full	break	or	fracture	only).		
 ........................................................................................................................................................................................................................................................................................


 Name:	.......................................................................................................................................................................................Qualifications:	....................................................... 	
 Telephone:......................................................	Email	address:	........	...........................	.............................................................................Fax:	...................................................... 	
 Address:	....................................................................................................................................................................................................................................................................... 	
 State:	....................................................................................................Postcode:	........................................................................................


 Signed:	..................................................................................................................................................................................................		Date:	...........	/...........	/..............................


 	                                                                                                              	                   	                                                                	Affix	Stamp	Here




25.11.2009                                                                                                                                                                                                                                                                             7

				
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