EditNew - Online Claim

Email Address
First Name
Last Name
Phone Number
Are you a broker submitting this form?				No Yes
Do you consent to receive important information about your claim via email?				No Yes
What kind of claim?

Before you proceed further with this claim, please ensure you have:

Policy number and Insured/Policy holder name
Date, time, location and description of accident
Details for preferred point of contact
Insured’s driver name and date of birth
Insured’s vehicle rego, make and model
Name of other involved parties including any witnesses

Policy No
Date of Birth
Full Address
Do you have a different address for correspondence?			No Yes

What is your occupation?

How many years have you been in this occupation?

years

How many hours do you work per week?

hours

When did you join your current employer or start operating your business?

List here all the duties of your occupation and the average time (percentage) you perform each duty per week

Percentage of time doing, and type of, sedentary/light duties

Percentage of time doing, and type of, manual duties

How long have you been performing the duties listed above?

years

In what occupations have you worked?

From

to (years)

Which of the following are you? (please tick)

An employee ... By whom are you employed/or for whom do you work? (business or company name)

Self employed ... What is your business structure? (eg. Sole trader/ partnership/company)

Do you have any employees?

No Yes

If so, how many

If you are/have been unable to work in your business because of sickness or injury, have your employees continued to work in your absence?

No Yes

What percentage of business expenses if any is your partner (or other person) responsible for?

A contractor

A subcontractor

Other ... Please provide details here

Were you admitted to hospital?

No Yes

Which hospital were you admitted to? (Attach a copy of the hospital admission or discharge summary in the next section)

Date admitted to hospital

Date released

Is the doctor that you have been seeing for your injury or sickness your usual treating doctor?

No Yes

How long have you been seeing this current doctor?

days

months

years.

Who is your usual treating doctor and what is the address of their practice?

Have you been referred to a specialist?

No Yes

Please provide the name and address of the specialist you have been referred to.

Specialist 1:

Are you still consulting the specialist?

No Yes

What tests have you undergone (for example CT scan, MEI, blood) and when? Please attach copies.

What medical treatment, including medication and therapies are you currently receiving and how frequently?

Please provide the following documents: Medical Certification Financial Certification A copy of your hospital admission or discharge summary Any other documentation to support your claim
Select type of document for upload					Download Medical Certification Download Financial Certification
This part of the claim form must be completed by a registered doctor who is certifying that the injured or sick person is, or was, disabled from working. Please note that any fee incurred for the completion of this medical certification form is the responsibility of the patient. Please note that medical certification is not accepted prior to the date you have first been consulted for this medical condition. If you are SELF EMPLOYED you must complete the first section on this page. You MUST provide a copy of your entire Individual Taxation Return & Notice of Assessment for the financial year immediately prior to your ceasing work due to your Injury or Sickness and if you are a company/partnership please also provide a copy of your entire Business Taxation Return. If you operate a Trust as part of your business structure you must also include a full copy of the entire Trust Taxation Return. If you are an EMPLOYEE, CONTRACTOR or SUB-CONTRACTOR, your employer or principal contractor must complete the second section on page 11. Acceptable proof of income includes a copy of your entire Individual Taxation Return AND Notice of Assessment for the financial year immediately prior to your ceasing work due to your Injury or Sickness. Claims which are not accompanied by the proof of income as requested above, CANNOT BE ASSESSED.
Please upload PDF files only.

Description					Date uploaded			Original document

Should your claim result in a payment being made to you, please provide us with your bank/direct deposit details.
Account Name
BSB No
Account Number

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Policy Details

Details of your occupation

Details of the injury claimed

Details of the sickness claim

Your medical treatment

Support Documents

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