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MEMBERS PERSONAL ACCIDENT INSURANCE CLAIM FORM

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MEMBERS PERSONAL ACCIDENT INSURANCE CLAIM FORM Powered By Docstoc
					                                        MEMBERS PERSONAL ACCIDENT INSURANCE
                                        CLAIM FORM
 IMPORTANT INFORMATION ABOUT YOUR CLAIM – PLEASE READ BEFORE COMPLETING THIS FORM
 The issue or acceptance of this form is not construed as an admission of liability on the part of the Insurance Company.
 Please print clearly and to avoid delays please ensure all relevant sections are completed.
 If you are claiming for Weekly Benefits :
      •    A 14 day excess applies
      •    Your weekly benefit entitlement pays 85% of your weekly earnings up to a maximum of $500 per week
      •    Proof of your earnings must be supplied
      •    Supporting medical certificates must be supplied
 If you are claiming for Non-Medicare Medical Expenses :
      •    They must be incurred within 18 months of the date of your injury
      •    Maximum benefit payable is $3,500
      •    $100 excess is applicable to each and every claim
      •    This policy does not cover any expenses claimable through Medicare including the gap.
      •    Where you hold Private Health Insurance it is mandatory for you to submit expenses to your fund first. You can then
           forward your provider’s Statement together with accounts to us for consideration.
 Please forward your completed claim form together with supporting documentation to :

     Aon Risk Services Australia
     GPO Box 514
     ADELAIDE SA 5001
 Should you have any questions relating to your claim please contact our office :

     Aon Risk Services Australia
     Phone : 1800 806 493
     Email : equestrian@aon.com.au

 SECTION ONE:                            COMPULSORY SECTION

 Personal Details                                Senior Member                        Junior Member                    (please tick)
                                                 Policy No 0018805                    Policy No 0018838

 Claimant’s Name:                        ________________________________________________                      Date of Birth:   ____/____/____

 Parent / Legal Guardian’s Name (where applicable) :________________________________________________________________________

 Postal Address:                         _______________________________________________ State:___________ Postcode: __________

 Daytime Telephone Number:               _________________________________            Mobile:   _______________________________________

 Email:                                  ____________________________________________________________________________________

 What is your occupation/trade or profession?

 What are you claiming for?              (Please circle)      Medical Expenses / Weekly Benefits / Other_____________________

 Please tick preferred form of payment for refund
     Cheque: Please nominate payee ____________________________________________________________________________________

     Direct Payment: Please supply the following information:         Account Name ________________________________________________

 Bank                                    Branch Number __________________            Account Number __________________________________

 Name of Club you are a member of ?

 What Association is this Club affiliated to ?

 Please provide your EA membership number:                                           In which state is your EA membership held?

 How long have you been an EA member?

 What is your main sport?                Dressage          Jumping        Eventing      Showing         Carriage       Vaulting
                                         Endurance         Other


Continued over page                                                  Page 1 of 5                                                         02/09
 Details of Injury
 Date of injury:                                                                                  Time of injury                        am / pm

 Describe your injury?                  ____________________________________________________________________________________

 Location where injury occurred:        ____________________________________________________________________________________

 Is this your home ?                    Yes / No            If No, why were you there



 Full details what you were doing at the time:

 ____________________________________________________________________________________




 At the time of the injury were you wearing a helmet (if accident occurred whilst riding)?        Yes / No


 Did injury result from the horse       Shying            Bolting            Kicking              Bucking
                                        Other


 At time of injury were you :           Competing           Training/Practicing              Having a Lesson          Club Activities

                                        Feeding             General Handling                 Pleasure Riding          Lunging


                                        Jumping             Other


 Was the accident witnessed?            Yes / No            If Yes, by whom, please provide their details :




 At the time of injury were you being paid or earning an income from the horse related activity ?                  Yes / No

 If Yes, please provide details :




 Medical Questions
 When did you first see a doctor for this condition?                                              Date:   _____/_____/_____

 Have you previously suffered from the same or a similar injury?                  Yes / No        Date:   _____/_____/_____

 Are there or do you envisage any complications?            Yes / No              If yes, give details: ______________________________________

 Do you have private health cover?      Yes / No            Type of Cover:


 Please note that if you have private health insurance you must first make a claim on them.

 Name & Phone number of initial         ____________________________________________________________________________________
 Medical Attendant

 Name & Phone number of your            ____________________________________________________________________________________
 regular Medical Attendant

 Is there anything in your medical history which may have contributed directly or indirectly, to the injury or which may be likely to retard your
 recovery?
                                        Yes / No           Give Details       ______________________________________________________

 Nature of operation /
 hospitalisation (if any)               ______________________________________                    Dates: ____/_____/____ to ____/____/____


 If you are unable to go to school or work, when do you expect to be able to return?              Date:   ____/_____/____




Continued over page                                                 Page 2 of 5                                                          02/09
 SECTION TWO:                                 COMPLETE ONLY IF CLAIMING FOR LOSS OF INCOME

 WE ARE UNABLE TO PROCESS BENEFIT PAYMENTS WITHOUT CONFIRMATION OF INCOME

 1.         IF SELF EMPLOYED PLEASE INDICATE BY TICKING THE BOX

 Confirmation of earnings MUST be submitted with claim form (eg. Income Tax Return or Profit/Loss Statement)

 2.         IF EMPLOYED AS A WAGE EARNER TO BE COMPLETED BY YOUR EMPLOYER

 I hereby certify that                                               has been unable to attend his/her usual occupation with the company as a result of an

 injury suffered whilst                                                                       on the     ______/______/______

 He/She has been incapacitated since ______/______/______ and is expected to/did resume duties on ______/______/______

 His/Her Gross Salary, exclusive of bonuses, commission, allowances etc. at the Date of Injury was                                                             p.w.

 During the period of incapacity he/she received: $                                           From:      ______/_______/______ to ______/______/______

 Please specify type of pay                                                                                               _____________
 (If there is insufficient room to specify pay types, please provide pay history copies or print-outs)
 Has been employed since                      ______/______/______

 Name of Company           _________________________________________________________________________________________________

 Address                   _________________________________________________________________________________________________

 Signature of Supervisor or Paymaster ______________________________________                             Name (Please Print)

 Telephone Number                                                                                        Date     ______/______/______




 SECTION THREE:                               COMPULSORY SECTION – DECLARATION AND AUTHORITIES

                                                              Dispute Resolution Statement
 Accident & Health International Underwriting Pty Ltd is an agent for Allianz Australia Insurance Limited who is a signatory to the General Insurance Code of Practice
 developed by the Insurance Council of Australia.
 If you have a dispute and after talking to Accident & Health International Underwriting Pty Ltd staff you are still dissatisfied and you wish to take the matter further we
 have a Complaints and Dispute Resolution Procedure which undertakes to provide an answer to your concerns within fifteen (15) working days.
 If you are not satisfied with our dispute resolution process, we will advise you on how to contact the insurance industry’s external independent complaints scheme.
 Access to the Dispute Resolution scheme is free of charge to you.

                                                                Declaration and Authorities
 Privacy:
 The Privacy Act 1988 requires us to tell you that on behalf of the Insurer we collect your personal information and sensitive information in order to calculate your loss
 and entitlements, determine our liability, compile data and handle claims.
 When handling claims we may have to disclose and obtain your personal and other information to and from third parties such as other insurers, re-insurers, loss
 adjusters, medical attendants, external claims data collectors, investigators and agents, to the Insurance Reference Services (IRS), or other parties as required by
 law.
 You have the right to seek access to your personal information and to correct it at any time. Please contact Accident & Health and advise us of the changes.

 Medical Authority:
 I authorise any doctor or medical attendant who has treated me or examined me or any person or organisation that employs or has employed me or any other
 person or organisation who has or may have information regarding my illness/injury to give the underwriter any information it requires to assist in the proof and
 settlement of my claim. A photocopy or faxed copy of this authority can be acted upon as if it were an original.

 Declaration:
 I/We certify that the information given in this form is truthful accurate and complete. No information likely to affect this claim has been withheld. I/We understand
 that this claim may be refused if information is untrue, inaccurate or concealed.
 I/We acknowledge that I/We have read and understood the Privacy Act 1998 information and Medical Authority referred to above and consent to the collection,
 storage and use and disclosure of my/our personal and sensitive information. I/We acknowledge that if I/We do not agree to the collection of this personal and
 sensitive information then Accident & Health will be unable to process my/our claim.

 (Please circle)
 Claimant / Parent / Legal Guardian’s Signature:              _________________________________________________________________________

 Date: ______/_______/______               Print Name:


 Please note we are unable to process any claim without a signed declaration.




Continued over page                                                          Page 3 of 5                                                                           02/09
                                          ATTENDING PHYSICIANS STATEMENT
                                  THE INSURED IS RESPONSIBLE FOR COMPLETION OF THIS FORM
                                             WITHOUT EXPENSE TO THE COMPANY



SECTION FOUR:                    TO BE COMPLETED ONLY IF CLAIMING FOR LOSS OF INCOME
1.     Patient’s Name

2.     Please give complete diagnosis of this condition



HISTORY

1.     When did the patient first receive medical treatment?                    /         /

2.     a) Is there a previous history of this or a similar condition?                         Yes                               No

       b) If Yes, please provide details



3.     a) How long have you known the patient?

       b) Are you the regular general practitioner?

       If not, please advise who is

INJURY / SICKNESS

1.     When did the patient first suffer the injury?

2.     What was the cause of the injury?

3  Are the injuries consistent with the cause of injury?                                      Yes / No
OR
4. When was sickness first contracted?                 /             /                   When did symptoms become evident?                        /           /

DEGREE OF DISABILITY

1.     When was patient obliged to cease work?

2.     When was/will the patient be able to return to work:

a)     Some duties?                   /          /                              OR            b) Full duties?                        /        /

TREATMENT OF PRESENT CONDITION

When were you consulted?                     a) Initially                /           /                b) Most recently                    /           /

                                                                                    Period of
Was patient confined to hospital?          Yes              No                      confinement                   /      /               To               /       /

If Yes, please advise Name and Address of hospital

What other surgical or medical procedures are possibly contemplated?

Are there any underlying conditions affecting recovery from the current conditions?                         Yes                               No

If Yes, could you advise the nature of underlying conditions and how they affect disability and recovery



What is the current prognosis?

Are there any further remarks which may assist in assessing this condition?



Date                                                   Signature                                                Qualification

Name (Please print)                                                                             Address

City or Town                                                       State                                    Telephone



Continued over page                                                          Page 4 of 5                                                                          02/09
SECTION FIVE: ACCIDENT / INJURY EXPENSE CLAIM FORM

                                                            A                 B            C                       Office Use Only
    Date
                                                                                      Health Fund
  Expense                Item Description               Fee Charged   Scheduled Fee                    Amount Payable          Details
                                                                                        Benefit
  Incurred




                                              Totals:


Please note that any expense which is claimable through Medicare is not claimable under this policy.




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