Total and Permanent Disability (TPD) Claim Form by lindahy


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									MLC Insurance

Total and Permanent Disability
(TPD) Claim Form
MLC Nominees Pty Limited        MLC Limited             The Universal Super Scheme
ABN 93 002 814 959              ABN 90 000 000 402      ABN 44 928 361 101
AFSL 230702 RSE L0002998        AFSL 230694             SFN 281 440 944 R1056778
Please fully complete this claim form (pages 1 to 6). If there is insufficient space to fully answer a question, please use page 5.

	        Scheme	Name	or	Employer	(Business)	Name
                                                                                              a. DisabiliTy DeTails
                                                                                          1	 Describe	the	exact	nature	of	your	medical	condition/s.
	        Policy	Number/Member	Number


        MeMber DeTails
                                                                                          2	 If	you	had	an	injury,	how	did	it	occur?
	        Mr		          					Mrs		     					Ms		   					Miss		         					Other		    	
	        Surname	(Family	Name)	(please	print)

	        Given	Name(s)	(please	print)                                                     3	 When	did	the	symptoms	of	your	medical	condition/s	first	appear?

                                                                                          	           /        /
	        Date	of	Birth                                                                    4	 When	did	you	first	consult	a	doctor	for	this	medical	condition/s?

                       /        /                                                         	           /        /
	        Country	of	birth                                                                 5	 Please	provide	details	of	all	healthcare	providers	(eg.	doctors,	
                                                                                               physiotherapists	etc),	you	have	consulted	and	the	date	first	and	
                                                                                               last	consulted	for	your	medical	condition.		
                                                                                               (Please	use	page	5	if	space	is	insufficient).
	        Home	address
                                                                                                Doctor’s	name	and	address

	        Postal	address	(if	different	to	home	address)
                                                                                                Doctor’s	Telephone	     (									)
                                                                                                Reason	seen

                                                          Postcode                              Date	first	consulted	           Date	last	consulted

	        Home	Number	                                   Work	Number
                                                                                                          /        /     	
                                                                                                                                       /         /
             (									)                                (									)
    	                                               	                                           Doctor’s	name	and	address
	        Mobile	number
             (									)
	        What	is	your	height	and	weight?                                                                                              Postcode

	            height	                (cm) 	              	 weight	              (kg)
                                                                                                Doctor’s	Telephone	     (									)
                                                                                                Reason	seen

                                                                                                Date	first	consulted	           Date	last	consulted
                                                                                                          /        /     	
                                                                                                                                       /         /
Page 1 of 8 TPD Claim Form
6	 Have	you	required	hospital	treatment	for	this	medical	condition/s?
                                                                                   b. OCCuPaTiOn anD inCOMe DeTails
    No	            		 Go to Question 7	            	
    Yes	           	 Provide details below                                     8	 What	was	your	job	title	and	who	was	your	Employer	at	the	time	you	
                                                                                    ceased	work?
      Name	of	Hospital/Doctor	and	Speciality


                                                                               9	 When	did	you	cease	work?	                   /   /       	

                                                                               10	 Why	did	you	cease	work?	
      Reason	seen                                                              11	 Describe	your	work	duties	in	detail,	including	the	type	of	duties	and	
                                                                                    and	percentage	of	time	doing	manual	and/or	non-manual	work.

                                                                                      Describe	type	of	duties
      Admission	date	                  Discharge	date
               /           /       	
                                                       /      /

      Name	of	Hospital/Doctor	and	Speciality

                                                                                      Percentage	of	Manual	work	                                      %

                                                                                      Percentage	of	Non-Manual	work	                                  %
                                                                               12	 Did	you	supervise	other	employees?
      Reason	seen
                                                                                        	     	 Go to question 13
                                                                                    Yes       How	many:

      Admission	date	                  Discharge	date
               /           /       	
                                                       /      /
	                                                                              13	 Which	duties	does	your	medical	condition	prevent	you	from	performing?

7	 Have	you	ever	had	this	or	any	similar/related	medical	condition/s	before?
    No	            		 Go to Question 8	            	
    Yes	           	 Provide details below

      Nature	of	condition/s                                                    14	 Prior	to	your	disability,	what	were	your	usual	hours	and	days	of	work	
                                                                                    in	a	week?

                                                                                      Hours	worked	per	week	        Usual	days	worked	per	week
      Date	of	episode/s		                              /      /
      Period/s	off	work                                                                                         	
                       /       /          	
                                                              /   /
                                                                                      Hours	worked	per	day
                       /       /          	
                                                              /   /
                                                                                      from                  am/pm       to                    am/pm
      Name	of	doctor	consulted                                                            	                         	     	



Page 2 of 8 TPD Claim Form
15	 Were	your	usual	hours	and/or	days	of	work	modified	in	any	way	during	       19	 Since	stopping	your	usual	work	have	you	worked	in	any	other	capacity?
    your	employment?                                                                No	              		 Go to Question 20	     	
    No	           	 Go to question 16                                               Yes	             	 Provide details below
    Yes           Reason/s	for	modification
                                                                                      Type	of	work

                  How	modified

                                                                                              	 Full	time	          		 Part	time
                                                                                      Date	started	 	                    Date	ceased
                  When	modified
                                                                                                 /           /      	
                                                                                                                                   /           /
                  	          (day)	           (month)	           (year)
          	                                                                           Employer’s	(Business)	name

16	 What	level	of	education	do	you	have	(eg.	Primary,	Secondary	or	Tertiary)?
                                                                                      Income	earned
17	 What	qualifications	or	certificates	do	you	have?                            	
                                                                                20	 Have	you	applied	for	any	jobs	since	stopping	work?
                                                                                    No	              		 Go to Question 21	     	
                                                                                    Yes	             	 Provide details below

                                                                                      Employer’s	(Business)	name

18	 Please	list	all	previous	jobs	you	have	held	(please	use	page	5	if	space	
    is	insufficient).                                                                 Job	title

      Employer’s	(Business)	name
                                                                                      Date	of	application
                                                                                                                          /            /
      Job	title                                                                       Were	you	offered	the	position?		No	                  	       Yes		
                                                                                      If	no,	please	provide	reasons	for	not	being	offered	the	position

      Work	duties

                                                                                      Employer’s	(Business)	name

                                                                                      Job	title
      Date	started	                     Date	ceased

              /          /                    /        /
                                                                                      Date	of	application
                                                                                                                          /            /
      Employer’s	(Business)	name                                                      Were	you	offered	the	position?		No	                  	       Yes		
                                                                                      If	no,	please	provide	reasons	for	not	being	offered	the	position

      Job	title

      Work	duties
                                                                                21	 Are	you	attending	any	rehabilitation	programmes	or	have	you	
                                                                                    commenced	any	studies	to	help	you	return	to	the	workforce?
                                                                                    No	              	 Go to question 22
                                                                                    Yes              Please	provide	details:

      Date	started	                     Date	ceased

              /          /        	
                                              /        /
                                                                                                                               Page 3 of 8 TPD Claim Form
                                                                               24	 Describe	your	current	daily	activities.
    C. OTher

22	 Are	you	making	a	claim,	or	have	you	ever	made	a	claim	for	this	
     condition	under	workers’	or	accident	compensation,	third	party	
     insurance	or	with	Centrelink,	Department	of	Veterans’	Affairs,	or	any	
     other	insurance	company	or	government	department?
     No	        		 Go to Question 23	     	
     Yes	       	 Provide details below
                                                                               25	 What	daily	activities	are	you	unable	to	do	because	of	your	
      Insurer/Department	name                                                      medical	condition/s?


                                          Postcode                             26	 Please	provide	details	of	any	sports/pastimes	that	you	have	been	
                                                                                   unable	to	continue	because	of	your	medical	condition?
      Claim	type	(eg	Workers’	Comp)

      Contact	person

      Claim	number

      Gross	Weekly	Benefit            $                                        27	 Provide	any	other	comments	which	may	assist	with	the	assessment	
	                                                                                  of	your	claim.

      Insurer/Department	name


      Claim	type	(eg	Workers’	Comp)

      Contact	person

      Claim	number

      Gross	Weekly	Benefit            $
23	 Do	you	have	any	other	source	of	income	(eg.	sick	leave,	investment	etc)?
     No	        	 Go to question 24
     Yes        Type	of	income

                Amount      $

Page 4 of 8 TPD Claim Form
 aDDiTiOnal inFOrMaTiOn:
 If	you	use	this	page	to	provide	additional	information,	please	note	the	page	and	question	number	to	which	the	additional	information	refers.

Page	Number              Question	Number           Additional	Information

                                                                                                                          Page 5 of 8 TPD Claim Form
  DisClOsure TO ClienT rePresenTaTive                                               DeClaraTiOn anD auThOriTy

To	assist	with	the	claims	process	you	may	want	a	family	member	or	friend	       1.	 I	declare	that	the	answers	on	pages	1	to	6	are	true	and	complete.		
to	receive	information	regarding	your	claim.                                        I	have	not	made	any	false	or	misleading	statement	and	I	have	
                                                                                    included	all	information	relevant	to	the	assessment	of	my	claim.
I	acknowledge	that	the	information	provided	may	include	any	information	
that	MLC	Limited	(MLC)	holds	about	me	in	respect	of	my	claim	including	         2.	 If	any	answers	to	the	questions	are	not	in	my	handwriting	I	certify	
health,	lifestyle,	employment,	financial,	and	insurance	information.                that	I	have	checked	them	and	they	are	correct.
I	authorise	the	people	listed	below	to	receive	information	on	my	behalf	        3.	 I	understand	that	if	I	do	not	give	the	information	requested	by	MLC	or	
about	my	claim.	They	have	been	made	aware	and	have	consented	to	their	              its	representative	that	MLC	may	not	be	able	to	assess,	investigate	or	
personal	details	(name,	date	of	birth	and	relationship	to	me)	being	given	to	       pay	my	claim.
MLC.	I	have	also	provided	them	with	a	copy	of	the	brochure	sent	to	me	by	
                                                                                4.	 I	understand	that	MLC	will	disclose,	collect	and	use	the	information	
MLC	which	details	how	MLC	handles	personal	information	and	privacy.
                                                                                    covered	by	this	Declaration	and	Authority	solely	for	the	purpose	of	
 1.	Name                                                                            its	administration	of	the	policy,	including	this	claim,	and	not	for	any	
                                                                                    other	purpose.
                                                                                4.1	 I	hereby	authorise	MLC	to	disclose	my	personal	information	(which	may	
 Relationship	to	me	                                                                 include	sensitive	or	health	information)	to	the	following	parties.	I	further	
                                                                                     consent	to	these	parties	collecting	information	about	me	and	releasing	
                                                                   	                 to	MLC	their	report,	including	any	information	they	may	hold	about	me	
                                                                                     as	relates	to	MLC’s	administration	of	the	policy,	including	this	claim.
 Date	of	birth	
         /        /                                                             	      A
                                                                                     •		 ny	physician,	hospital	or	any	other	healthcare	provider	who	has	
                                                                                       attended	or	examined	me	in	order	for	them	to	supply	MLC	with	full	
                                                                                       particulars	of	my	medical	history	including	copies	of	all	hospital	or	
 2.	Name                                                                               medical	records,	referral	letters,	reports	and	details	of	any	clinical	
                                                                                       notes	that	have	been	made.
                                                                                     •		 ny	claims	assessor,	investigator,	medical	professional,	healthcare	
 Relationship	to	me	                                                                   provider,	insurance	reference	service,	credit	reference	service,	
                                                                                       legal	or	accounting	firm,	auditor,	employer,	consultant	or	reinsurer	
                                                                   	                   for	the	purposes	of	producing	a	report	concerning	my	claim.
 Date	of	birth	                                                                 	      A
                                                                                     •		 ny	benefit	provider	such	as	other	insurers	or	government	
         /        /                                                                    departments	(including	workers’	compensation	insurers,	
                                                                                       Centrelink	or	similar	benefit	providers)	that	provides	benefits	
                                                                                       in	the	event	of	my	sickness	and/or	injury.	
                                                                                4.2	 I	authorise	MLC	to	provide	my	Financial	Adviser	with	copies	of	all	
                                                                                     correspondence	(which	may	include	personal	and	sensitive	information)	
                                                                                     between	MLC	and	myself	in	respect	of	the	claim.	I	also	authorise	my	
                                                                                     Financial	Adviser	to	make	inquiries	regarding	the	progress	of	the	claim	
                                                                                     for	the	purpose	of	providing	me	with	ongoing	service.
                                                                                5.	 A	photocopy	of	this	authority	is	as	valid	as	the	original.
                                                                                Name	of	Member	(please	print)


                                                                                    ✗	                                          		   Date	 					/					 /

                                                                                Please	attach	copies	of	any	reports	and/or	test	results	relating	to	
                                                                                your	current	medical	condition	you	may	have	in	your	possession.
                                                                                Return	this	form	and	any	attachments	to:
                                                                                Claims	Department	
                                                                                MLC	Limited	
                                                                                PO	Box	200,	
                                                                                North	Sydney	NSW	2059

Page 6 of 8 TPD Claim Form
This	page	has	been	left	blank	intentionally.

                                               Page 7 of 8 TPD Claim Form
                                                                     How	to	contact	us
                                                                 MLC	Client	Service	Centre
                             If	you	have	any	questions,	please	contact	your	financial	adviser,	
                              or	the	MLC	Client	Service	Centre	on	132	652	any	business	day	
                                                 between	8.00	am	–	6.00	pm	(Sydney	time).
                                                                            Postal	address	
                                                                       MLC	Trustee	Services	
                                                                               PO	Box	1585	
                                                                    North	Sydney	NSW	2059

                                   For	details	on	MLC’s	range	of	products	and	services	visit:	

                                                                                              54119 MLC 0309

Page 8 of 8 TPD Claim Form

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