COMPLETE CLAIM FORM

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SECTION A - CLAIMANT STATEMENT
CLAIMANT'S DETAILS

What specified serious medical condition are you suffering from?

CARDIOVASCULAR

Angioplasty

Cardiomyopathy

Myocardial Infarction (Heart Attack)

Open Heart Surgery

Primary Pulmonary Hypertension

NERVOUS SYSTEM

Coma

Dementia/Alzheimer’s Disease

Encephalitis

Motor Neurone Disease

Multiple Sclerosis

Muscular Dystrophy

Paralysis

Parkinson’s Disease

Stroke

ORGANS

Benign Brain Tumour

Cancer

Chronic Liver Disease

Chronic Lung Disease

Chronic Renal Failure

Major Abdominal Aortic Surgery

Major Organ Transplant

OTHER

Aplastic Anaemia

Loss of Speech

Loss of Independent Existence

Major Head Trauma

Total Blindness

Total Deafness

Severe Burns


     Yes           No
Have you or are you planning to lodge a motor accident compensation claim?      Yes           No
Have you or are you planning to lodge a sports insurance claim?      Yes           No
Have you or are you planning to lodge a Workers' Compensation claim?      Yes           No
Have you or are you planning to lodge a claim for any Local, State or Federal Government benefits?      Yes           No
Are you making or entitled to lodge a claim or claim compensation benefit from any other insurer?      Yes           No

If you have answered "Yes" to any of the above, please complete the below, provide and upload(Word,pdf,jpeg) details of your claim . For example, an acceptance or decline letter and copies of any benefits.
Insurer/Company name
Type of claim
Address
Contact person
Have you received or are you eligible for any employer benefits? Sick leave, Personal leave etc.      Yes           No
AUTHORISED REPRESENTATIVE(S).

Complete this section if you wish to authorise a family member or friend to assist you with the claims processs (including ordering services/products). This may involve disclosure of personal information about your claim which potentially includes medical, financial, employment, and insurance information.


Name of authorised respresentative
Representative's relationship to you
Representative's date of birth

DECLARATION AND AUTHORISATION
PRIVACY STATEMENT
In this statement “we”, “us” and “our” means Windsor Income Protection (AFSL 400598) a coverholder of Lloyd's of London, on behalf of My Practical Support.

We are bound by the obligations of the Privacy Act 1988 as amended by the Privacy Amendment (Enhancing Privacy Protection) Act 2012. This sets out basic standards relating to the collection, use, storage and disclosure of personal information.

Our Privacy Policy, available at www.windsorip.com.au or by calling us, sets out how:
• we protect your personal information;
• you may access your personal information;
• you may correct your personal information held by us;
• you may complain about a breach of the Privacy Principles or Registered Privacy Code and how we will deal with such a complaint.

We, and our agents, need to collect, use and disclose your personal information in order to consider your application for insurance and to provide the cover you have chosen, administer the insurance and assess any claim. You can choose not to provide us with some of the details or all of your personal information, but this may affect our ability to provide the cover, administer the insurance or assess a claim.

We may disclose your personal information to third parties who assist us in providing the above services. These parties (which include our related entities, distributors, agents, insurers (including reinsurers) and service providers) will only use the personal information for the purposes we provided it to them for (unless otherwise required by law). Some of these parties may be located outside of Australia which includes but is not limited to the United Kingdom.

Information will be obtained from individuals directly where possible and practicable to do so. Sometimes it may be collected indirectly (e.g. from your representatives or co-insureds). If you provide information for another person you represent to us that:
• you have the authority from them to do so and it is as if they provided it to us;
• you have made them aware that you will or may provide their personal information to us, the types of third parties we may provide it to, the relevant purposes we and the third parties we disclose it to will use it for, and how they can access it. If it is sensitive information we rely on you to have obtained their consent on these matters. If you have not done or will not do either of these things, you must tell us before you provide the relevant information.

You are entitled to access your information if you wish and request correction if required. You may also opt out of receiving materials sent by us by contacting My Practical Support on 1800 000 000 or via email at claims@mypracticalsupport.com.au.

For information about how My Practical Support treats your personal information, please refer to its Privacy Policy and Privacy Collection Notice at www.mypracticalsupport.com.au

1. I hereby authorise Windsor Income Protection Pty Ltd on behalf of My Practical Support to disclose my personal information to any of the following parties: Any authorised representative of Windsor Income Protection Pty Ltd, My Practical Support, my authorised representatives, employer and any physician, hospital, healthcare provider who has attended or examined me in order for Windsor Income Protection Pty Ltd to be supplied with my full medical history including but not limited to any medical or hospital records, reports, clinical notes and referral letters.

2. I hereby authorise and consent to Windsor Income Protection Pty on behalf of My Practical Support to collect any information for the assessment of my claim from any of the following: My Practical Support, Employer(s), workers compensation insurer, insurance companies, government department (which includes Centrelink or similar benefit providers), claims assessor, legal firm, physician, hospital, healthcare provider who has attended or examined me in order for Windsor Income Protection Pty Ltd to be able to be supplied with my full medical history including but not limited to any medical or hospital records, reports, clinical notes and referral letters.

3. I understand that this claim and any future claims may be refused if any information I’ve provided is not true, misleading or relevant information has been withheld.

4. A photocopy, emailed or scanned (Word, pdf, jpeg) copy of this authority is considered as effective and valid as the original.


I hereby declare that all information supplied is true and correct in every aspect. I have not made any false or misleading statements.
YOUR NAME JOHN SMITH (AUTO)
DATE 27/08/2015
SECTION B - DOCTOR'S STATEMENT (must be completed by your regular Treating Doctor)






 
Are you the patient’s regular Doctor?      Yes           No
How long has this patient been attending your practice/hospital?
When did the patient first attend your practice for the current condition?
When did the patient’s symptoms first appear or injuries occur?
When was the patient diagnosed?
 
Please state the primary medical diagnosis that has medically debilitated or incapacitated the patient
If any, please list all other medical conditions affecting a return to work
What is the cause of the patient’s current debility / incapacity?
Please provide details of the patient’s symptoms
Please advise the prescribed medication and treatment given to the patient
Are there any complications regarding the patient’s recovery?      Yes           No
If “Yes”,  please give details below of the similar condition, date condition became apparent and contact details of the doctor/specialist consulted.
Has the patient had a similar condition in the past?      Yes           No
If “Yes”, please give details below of the similar condition, time of onset and contact details of the physician/specialist attended for that condition.  
Medical condition Condition first occurred
 
DOCTOR'S NAME PRACTICE/HOSPITAL NAME CONTACT NUMBER DATE ATTENDED

In your professional opinion, do you believe this condition is work related?      Yes           No
In your professional opinion, do you believe this condition is sports related?      Yes           No
Has the patient been following your prescribed medication and treatment?      Yes           No
If "No", give details of when the patient did not follow medical advice.
Does the patient require any further treatment or advice?      Yes           No
If "Yes", please advise what further treatment is required.
In regards to the patient’s medical condition, have you issued any certificates or forms to any other insurance companies, worker's compensation or government entities?      Yes           No
If "Yes", please advise to which entity.
In your opinion, does the patient require surgery for this condition?      Yes           No
If "Yes", has surgery been undertaken?      Yes           No
DOCTOR's DECLARATION AND AUTHORITY

I hereby certify that I am a registered medical practitioner and have examined the above named patient and that all information that I’ve supplied is true and correct. I also acknowledge that Windsor Income Protection Pty Ltd may provide copies of these forms to any required representative and or third parties deemed necessary to assist the ongoing assessment of the claim.

Practice/Hospital name
Name (please print)
Address
Suburb
Phone number
Email
In your professional opinion, when do you believe that the patient will no longer be medically debilitated or incapicitated as a direct result of his/her serious medical condition?

Definition of "medically debilitated or incapicitated"

When a Patient becomes very weak, infirm or has been deprived of strength or power by suffering sickness or injury which in the opinion of a Medical Practitioner is expected to:
1. cause the Patient to be incapacitated for work for a period of at least 7 consecutive days; or
2. cause the Patient to be hospitalised for a period of at least 7 consecutive days; or
3. cause the Patient to be receiving treatment for at least 7 consecutive days.

NOTE - It would really assist the patient's claims process if you are able to supply start and end dates when issuing medical certificates.