GROUP SALARY CONTINUANCE CLAIM FORM by lindahy

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									                                                                                               GROUP SALARY
                                                                                               CONTINUANCE
                                                                                               CLAIM FORM


                         STATEMENT BY LIFE INSURED. All questions MUST be answered fully.


SECTION A – PERSONAL DETAILS

Plan Name                                                                                          Policy Number

Name of Life Insured                                                                               Member Number
                                                                                                                                          Postcode
Residential Address
                                  Home                                   Work                                   Mobile
Telephone

e-mail (for correspondence)

Date of Birth                            /    /            Age                  When did you cease work ?                     /      /



SECTION B – CLAIM DETAILS (complete A or B below)

A. Injury Claim.     Answer all of Section A (questions 1 to 5 below,) if your claim is in respect of an injury.


1. What is your injury ? (Provide full details of the nature and extent of your injuries. If to a limb, specify whether left or right.)




2. When did the injury occur?                                          Date            /       /         Time                     am/pm

3. Where did the injury occur?



4. How did the injury happen and what caused it.




5. Were there any witnesses to the injury ? If so, please provide their names and contact details (if known).




B. Sickness Claim.      Answer all of Section B (questions 1 to 4 below), if your claim is in respect of a sickness.

1. What is the nature of your sickness?



2. When did your symptoms first occur?
                                                                                   /       /
3. When was a diagnosis made?
                                                                                   /       /



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                                                                                                     CONTINUANCE
                                                                                                     CLAIM FORM


4. Please provide the name and address of the doctor or medical provider who made the diagnosis




SECTION C – TREATMENT FOR THIS CONDITION


1. (a)          When did you first consult a doctor or medical provider for your condition?           /   /

                Name of the doctor or medical provider consulted

                Address


                Field of Practice (ie. GP, cardiologist, etc.)
     (b) When did you last consult this doctor or medical provider?                                   /   /
     (c)       Is this your usual doctor or medical provider?                 Yes              No.
               If No, please provide the name and address of your usual doctor or medical provider

                                      Name

                                      Address


     (d) How long have you attended your usual doctor or medical provider?
     (e) Have you consulted any other doctors and/or medical providers for your condition?                    Yes         No
               If ‘Yes’, please provide details below (attach a separate sheet if required).
     Date first                  Date Last                       Doctors Name /
                                                                                                                    Address
     Consulted                   Consulted                       Field of Practice

           /       /              /       /


           /       /              /       /


           /       /              /       /


           /       /              /       /



2.         Were you hospitalised?               No         Yes
           If ‘Yes’, please provide details below (attach a separate sheet if required).
                    Hospital Name                                           Address                       Date Admitted        Date Discharged

                                                                                                               /      /            /     /


                                                                                                               /      /            /     /


                                                                                                               /      /            /     /



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                                                                                        CONTINUANCE
                                                                                        CLAIM FORM


3. Are you entitled to receive sick leave from your employer for your present disablement? If so, how many days leave ?




4. Have you ever had the same or similar injury/sickness before ?              Yes                     No
(If ‘Yes’, please advise the dates of when the injury/sickness occurred, what the nature of the injury/sickness was and the names of
any doctors or medical providers you consulted. Attach a separate sheet if required.)




SECTION D – MEDICAL HISTORY

1. Give the dates and reasons for all other consultations with your usual doctor or medical provider during the last 5 years.

Date            Reason




2. Have you attended any other doctor or medical provider (other than your usual doctor or medical provider) during the last 5 years ?
If ‘Yes’, give details below.

Date            Reason                                                   Name & Address of Doctor




3. What medications have you taken during the last 5 years ? (other than for colds or influenza)




4. Have you been disabled or incapacitated through any other injury or sickness in the last 12 months ? If ‘Yes’, please advise the
nature of the injury/sickness and how many days sick leave you required ?




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                                                                                            CONTINUANCE
                                                                                            CLAIM FORM


SECTION E – OCCUPATIONAL DETAILS

A. Employees (Answer questions 1 to 13 if you are an employee)

1. What is your Employer’s name and address?




2. What was your job title when you stopped work?



3. Please give details of your work duties                                            Duties                                     %




4. Was your employment                                                   Full-time              Part-time        Casual

5. In what areas did you work? (eg office, factory, building site)

6. How long have you been in that job?

7. How many hours per week did you work?

8. Did you supervise other employees?                                    Yes          No

9. Did you operate machines or any special equipment?                    Yes          No.       If Yes, please provide details




10. Please indicate ( ) the following requirements of your usual job, where applicable
                                    A       B      C     D                                                   A     B       C       D
Lifting, 20 kgs & over                                                               Carrying, 20 kgs & over
Lifting, 5 to 19 kgs                                                                 Carrying, 5 to 19 kgs
Lifting, under 5 kgs                                                                 Carrying, under 5 kgs
Reaching above shoulders
      A = never, B = occasional (1/3 of time or less), C = frequently (1/3 to 2/3 of time), D = continuous (more than 2/3 of time)

11. What percentage of time, on average, did you spend in the following activities while performing your usual job?
Sitting                              %            Standing                                 %                Walking                     %
Bending                              %            Lifting                                   %               Driving                     %
Climbing                             %            Crawling                                 %                Kneeling                    %

12. Were you required to travel as part of your job ?                                Yes            No
    If ‘Yes’, how may kilometres per week and type of vehicle


13. How far from home was your place of employment and how did you get there ?




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                                                                                         CLAIM FORM



B. Self-Employed (Answer Questions 1 to 12 if you are self-employed)

1. Are you a             Sole trader            Partnership              Company            Trust
2. What is the name of your business?



3 (a). If a partnership, what is your share of partnership (income and expenses) distribution?                    %
  (b) How many partners are there?
4. What duties did you perform in the business ?                                         Duties                              %




5. Please indicate ( ) the following requirements of your usual job, where applicable
                                  A        B      C     D                                                   A      B       C      D
Lifting, 20 kgs & over                                                             Carrying, 20 kgs & over
Lifting, 5 to 19 kgs                                                               Carrying, 5 to 19 kgs
Lifting, under 5 kgs                                                               Carrying, under 5 kgs
Reaching above shoulders
     A = never, B = occasional (1/3 of time or less), C = frequently (1/3 to 2/3 of time), D = continuous (more than 2/3 of time)

6. What percentage of time, on average, did you spend in the following activities while performing your usual job ?
   Sitting                             %        Standing                             %            Walking                         %
   Bending                             %         Lifting                             %            Driving                         %
   Climbing                            %         Crawling                            %            Kneeling                         %

7. How many employees does your business have?

8. What are their work responsibilities?




9. Since you ceased all work, has your business continued to operate in any way ? (If ‘Yes’, please detail what activities have
continued.)




10. If your business has continued, what impact has your disability had on the business?




11. Who has been operating your business in your absence?


12. How long will your business continue to operate during your absence?




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SECTION F – LEVEL OF DISABILITY

1.     Are you, as a direct result of your condition, totally disabled from working in your normal occupation?
            No               If ‘Yes’, please state which of your normal work duties you can and cannot do. If you can perform some of
                              your duties, but with restrictions, please note the restrictions

                       Work duties you can do                                                  Work duties you cannot do




2.     Since ceasing work, have you been able to work in any capacity (full or part-time, paid or unpaid) ?
            No
            Yes      Please give details (including employer name, job title, duties performed, period worked and the income earned).




3.     Have you applied for any jobs since ceasing work?
            No         Yes    Please give details (including dates, employer, job title and reason given for unsuccessful application).




4. If still disabled, when will you be able to return to work?                  /        /



5. If no longer disabled, when did you resume work?              Part time      /        /          Full time       /      /



SECTION G – VOCATIONAL HISTORY


 1.   At what age did you leave school?



 2. What is your level of education?      Primary         Secondary                 Tertiary




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                                                                                           CONTINUANCE
                                                                                           CLAIM FORM



3. (a) Please provide a detailed education history of all secondary, tertiary, TAFE courses (attach a separate sheet if required or your
       resume).
                            Course Description/Qualification                                      Dates Started     Date Qualified
                                                                                                        /      /            /        /
                                                                                                        /      /            /        /
                                                                                                        /      /            /        /
                                                                                                        /      /            /        /
                                                                                                        /      /            /        /



3. (b)    Please list any other courses or job related training undertaken (attach a separate sheet if required or your resume).
                              Course Description/Qualification                                      Dates Started      Date Qualified
                                                                                                        /     /             /        /
                                                                                                        /     /             /        /
                                                                                                        /     /             /        /
                                                                                                        /     /             /        /




4.       Please provide a detailed work history for the last 20 years (please attach a separate sheet if required or your resume).
         Period of Employment                        Position Description                               Duties Performed
                    -
                    -
                    -
                    -



SECTION H – FINANCIAL INFORMATION

1. What were your average monthly earnings for the last 12 months?                        $                        *
2. What were your earnings for the last financial year (1 July to 30 June)?               $                        *
* Net of business expenses but before tax. If you are an Employee, income includes all commission, bonuses paid, fees and fringe
benefits. If you are Self Employed, income is the gross income derived from personal exertion after deducting your share of the
business expenses.
                                 Financial evidence may be required to confirm these figures.

3. Please provide your Accountant’s name, address and                   Name
telephone number
                                                                        Address



                                                                        Telephone




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                                                                                           CONTINUANCE
                                                                                           CLAIM FORM



SECTION I – OTHER INSURANCES


1. As a result of your disability are you entitled to receive, or are you receiving any other benefit or are you entitled to claim any other
benefits? (eg Workers Compensation, Transport Accident Commission, Third Party Insurance, Centrelink, Income Protection,
Superannuation, Salary Continuance or any other insurance)
        No
        Yes Please provide Type of Claim
                                Insurer (if applicable)
                                Reference Number                                        Gross Amount of Claim       $               per week
                                Contact Person
                                Contact Number



2. Do you have any other sources of income ? If ‘Yes’, please                 No
provide details.
                                                                              Yes




3. Have you previously made a claim against us (AIG/AIA) in                   No
respect of this or any other injury, sickness or disability ?
                                                                              Yes, please provide details




SECTION J – DECLARATIONS AND AUTHORITIES

DECLARATION

I declare that the information in this Claim Form is true, correct and complete. I understand and agree that if I make any false or
fraudulent statements or fail to advise American International Assurance Company (Australia) Limited of any relevant information
regarding my claim, American International Assurance Company (Australia) Limited may refuse to pay benefits and proceed to cancel
my claim and/or my insurance cover. I understand that I may be prosecuted if I make a fraudulent statement.

I declare that I have read and understood the Privacy Statement attached to this claim form and I consent to the collection, use and
disclosure of my personal and sensitive information in the manner described in that Privacy Statement.

I authorise my previous and current employer to provide American International Assurance Company (Australia) Limited details of my
employment history.

                      I agree that a copy of this authorisation shall be considered as effective and valid as the original.

Name (Please
Print)

Insured’s signature                                                                                  Date                /      /




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                                                                                             CONTINUANCE
                                                                                             CLAIM FORM


AUTHORITY TO OBTAIN INFORMATION

I hereby authorise any insurer or other institution to release to American International Assurance Company (Australia) Limited or its
representatives all information which American International Assurance Company (Australia) Limited requests for the purpose of
assessing or investigating my claim.
                   I agree that a copy of this authorisation shall be as effective and valid as the original.
Name (Please
Print)

Insured’s Signature                                                                                                             /           /
                                                                                            Date



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ACCOUNTANT/FINANCIAL ADVISER AUTHORITY

I hereby authorise my previous and current accountant/financial adviser to release to American International Assurance Company
(Australia) Limited or its representatives all information which American International Assurance Company (Australia) Limited requests
for the purpose of assessing or investigating my claim.
                    I agree that a copy of this authorisation shall be as effective and valid as the original.
Name (Please
Print)

Insured’s Signature                                                                                                                 /           /
                                                                                            Date



 -----------------------------------------------------------------------------------------------------------------------------------------------


MEDICAL AUTHORITY

I hereby authorise any medical practitioner, medical provider, health professional, hospital, dentist or other person who has attended
me, to release to American International Assurance Company (Australia) Limited or its representatives all information with respect to
any illness or injury, medical history, consultations, prescriptions, or treatment and copies of all hospital or medical records.
                     I agree that a copy of this authorisation shall be as effective and valid as the original.
Name (Please
Print)

Insured’s Signature                                                                                                         /           /
                                                                                            Date



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                                                                                              MEDICAL ATTENDANT’S
                                                                                              STATEMENT


                        (To be completed by the Medical Attendant first consulted for this Disability)
              If there is a charge for completing this form, its payment is the responsibility of the claimant.

Patient’s Name                                                                                Date of Birth              /     /

Address

Occupation




1.       How long have you known this patient?                               Professionally                    Personally



2. (a)     Are you the patient’s usual doctor?        Yes         No If ‘No’, please advise the name and address of his/her usual doctor.

                                                    Name of usual doctor
                                                    Address



      (b) If the patient was referred to you,         Name of referring
          please advise:                              doctor.
                                                      Address




3.        What is your patient’s height and weight?                        Height               cms           Weight                   kgs




4.       Does your patient smoke?                                                Yes          No
         If ‘Yes’, please state in what form, quantity and how long
         he/she has smoked?




5.      Please describe the nature and extent of the patient’s condition, its probable cause (if known) and the level of disability.




6. (a) (i) On what date did the condition first occur?        /       /     (ii) Is the patient still receiving treatment?   Yes         No

     (b) Please advise the date that total disablement commenced?                   /   /




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                                                                                                MEDICAL ATTENDANT’S
                                                                                                STATEMENT




7. (a)      When were you first consulted for this condition?          /      /
     (b)    Please provide dates of all subsequent consultations.




      (c) Are there any factors affecting or prolonging the condition? For example, does the patient have any contributing, concurrent
          or pre existing conditions?

                  No                 Yes. Please provide details




8.         If any tests or investigations have been performed (ie. x-ray, etc.) please provide results (or attach a copy of applicable reports
           if available).




9. (a)      What is the diagnosis and what are the objective clinical signs of the condition?




     (b)    What is the prognosis?




     (c)    Has the patient suffered from this or a similar condition previously?          No           Yes. If ‘Yes’, please provide details.




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9. (d)    Has the patient been referred to any other doctor or medical provider for treatment or consultation?       Yes         No
          If ‘Yes’ please state:   Date of referral                                           /      /
                                   Name
                                   Address


                                   Field of Practice (Cardiologist, Ortho Surgeon, etc)

                                   Date of referral                                           /      /
                                   Name
                                   Address


                                   Field of Practice (Cardiologist, Ortho Surgeon, etc.)

                                   Date of referral                                           /      /
                                   Name
                                   Address


                                   Field of Practice (Cardiologist, Ortho Surgeon, etc.)



10.        What is the current treatment plan?




11. (a) To the best of your knowledge is the patient following the treatment plan prescribed?              Yes             No.
           If, ‘No’, please comment.




      (b) Do you consider any other treatment plan necessary?                     No         Yes. If ‘Yes’, please comment.




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                                                                                             MEDICAL ATTENDANT’S
                                                                                             STATEMENT




11. (c) What medical, surgical, rehabilitation or other treatment have you scheduled?




    (d)    Has the patient been involved in a rehabilitation program?
                  Yes. If ‘Yes’, please provide details            No. If ‘No’, would the patient benefit from such a program?




 12. Was the patient hospitalised?                 No            Yes. Please provide details below (attach a separate sheet if required).
 Date Admitted          Date Discharged                   Hospital Name / Address                          Condition / Procedure
       /     /      -       /      /




       /     /      -       /      /




       /     /      -       /      /




13. Have you given any other certificates concerning the patient’s disability?             No        Yes. If ‘Yes’, please provide details.


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14. (a) To the best of your knowledge, what are the duties of the patient’s normal occupation?




   (b) Does your patient work            Full time       Part time             Casual
   (c) On what date was the patient first unable to perform all the duties of his/her normal occupation?              /           /
   (d) Please list the duties that, at the current time, the patient cannot perform.




   (e) How long do you expect the patient to be unable to perform these duties?
   (f) Is the patient able to perform any kind of work?                                  No          Yes, from    /       /
         If ‘Yes’, please provide details.




   (g)    If still unable to work, when do you expect that your patient will be able to return to work ?
                 Part-time           Date            /   /                              Full-time          Date               /       /



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                                                                                       MEDICAL ATTENDANT’S
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                                          ADDITIONAL REMARKS AND PROGNOSIS
                         Please comment on any special matters regarding your patient and his/her condition.




            I certify that I have personally attended the above-named patient and that the above statement is correct.

Name (please print)                                                     Qualification(s)

Signature                                                               Date                      /      /

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            MEDICAL ATTENDANT’S
            STATEMENT


                           Postcode
Address

Telephone




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                                                                                    PRIVACY STATEMENT




American International Assurance Company (Australia) Limited ABN 79 004 837 861 AFS Licence No 230043 (AIA) trading as
AIG Life is required under the National Privacy Principles of the Privacy Amendment (Private Sector) Act 2000 to provide you
with the following information.

Purpose of Collection
AIA collects personal and sensitive information about you to process your claim(s) and, if appropriate, to pay benefits under the
policy. If you do not provide us with all or part of the personal and sensitive information we request from you, or if that
information is not accurate and true, we may not be able to process your claim or pay you a benefit.

Access to Your Information
You are entitled at any time to request access to your personal information held by AIA. All requests to access your personal
information should be made in writing to the Compliance Manager, Level 3, 549 St Kilda Road, Melbourne, Vic. 3004

You can ask us to update your personal information at any time if it is inaccurate, incomplete or out of date.

In some circumstances, AIA may not permit access to your personal information. Circumstances where access may be denied
include where access would be unlawful or denying access is authorised by law.

In these cases, AIA will provide you with written reasons for denial of access or a refusal to correct personal information.

Disclosure of Information
AIA may disclose your personal information to:

(a)   Another member of the AIG group of companies (whether in Australia or otherwise);
(b)   Your adviser;
(c)   AIA contractors and third party service providers (e.g. medical practitioners, reinsurers, investigators and accountants);
(d)   Your employer;
(e)   Financial institutions you nominate;
(f)   Government authorities to which we are required by law to disclose information (e.g. Australian Taxation Office).

We will only disclose your personal information to these parties for the purpose for which it was collected as stated above. In
some circumstances, AIA is entitled or required to disclose your personal information to third parties without your authorisation,
such as law enforcement agencies or government authorities to protect our interests or to report illegal activities.

Any Questions or Concerns
If you have any questions or concerns about your personal information please write to the Compliance Manager Level 3, 549
St Kilda Road, Melbourne, Vic 3004

AIA has established an internal dispute resolution process for handling customer complaints about AIA‘s compliance with the
National Privacy Principles. This dispute resolution mechanism is designed to be fair and timely to all parties and is free of
charge.

If you have a complaint about AIA’s compliance with the National Privacy Principles, you should submit it in writing to the
Compliance Manager. You will receive a letter from AIA within 5 working days, which documents AIA’s complaints handling
process. Your complaint will be referred to AIA’s Internal Dispute Resolution Committee who shall endeavour to resolve your
complaint within 45 days of receipt.

Should your complaint not be resolved to your satisfaction by AIA’s internal dispute resolution process, you may take your
complaint to the Privacy Commissioner. The Privacy Commissioner’s contact details are: Office of the Federal Privacy
Commissioner, GPO Box 5218, Sydney NSW 2001 or call the Privacy Hotline on 1300 363 992.




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