Get documents about "Total and Permanent Disability (TPD) Claim Form
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Total and Permanent Disability (TPD) Claim Form
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- 64
- posted:
- 3/27/2010
- language:
- English
- pages:
- 8
Document Sample
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
Postcode
Postcode
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
Address
9 When did you cease work? / /
10 Why did you cease work?
Postcode
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 %
Address
Percentage of Non-Manual work %
12 Did you supervise other employees?
Postcode
Reason seen
No
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
from
/ /
to
/ /
Hours worked per day
from
/ /
to
/ /
from am/pm to am/pm
Name of doctor consulted
Address
Postcode
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?
Address
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
Address
Postcode
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.
A
• 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)
Signature
✗ 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
Website
For details on MLC’s range of products and services visit:
mlc.com.au
54119 MLC 0309
Page 8 of 8 TPD Claim Form
