Claims form

Title

First name

Last name

Email

Best contact number

10 digit mobile number excluding spaces. For landlines, please include two digit area code

Plan number

This is your plan number beginning with F and followed by 9 digits which can be found on your plan schedule.

Please select the type of claim you’re submitting

Please select

What is the nature of your condition?

On what date was the condition diagnosed, or the trauma occurred?

What is the nature of your illness?

Has your doctor indicated that your life expectancy is less than 24 months?

Yes

No

What is the nature of your injury or illness?

Is your condition a result of an accident?

Yes

No

OtherOther

When did you first experience symptoms of this condition?

When did you first see a doctor for this condition?

When was your last day at work?

Have you returned to any work?

Yes

No

When do you expect to return to work part time?

When do you expect to return to full time work?

What is your occupation?

Are you self employed / an employee?

Self employed

Employee

What was your estimated income from your occupation in the past 12 months?

If you are self employed, this means your share of net profit after expenses, before tax.

Have you made, or do you intend to make any other claims as a result of this condition?

E.g. Workers Compensation, CTP, other disability cover, mortgage protection insurance.

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