accident and sickness questionnaire

This cover provides a weekly accident and sickness benefit (when selected) in the event that an insured person has an accident or contracts a sickness and cannot work. The benefit covers 85% of salary, or the sum insured, whichever is the lesser, and is paid for up to 104 weeks depending on the age of the insured person. Accidental death and loss of limbs through an accident can also be covered.

Standard Benefits:

  • Death and Capital Benefits - up to $500,000
  • Weekly Injury - 85% of Salary up to a maximum of $2,000 per week
  • Weekly Sickness - 85% of Salary up to a maximum of $2,000 per week
  • Benefit period - 104 weeks (52 weeks if over 59 years old)
  • Excess - either 7, 14, 21 or 28 days (some occupations attract a minimum excess of 14 days)
  • Salary does not include overtime and allowances unless specifically agreed

Note: Pre-Existing Medical Conditions are excluded

YOUR CONTACT DETAILS
Your Name
Contact Phone Number
Fax Number
Email Address
Postal Address
PERSONAL ACCIDENT AND SICKNESS
What is your occupation?
Describe you occupational duties
Are you self employed?
Do you require cover for after hours work?
What is the predominant state in which you work?
Are you male or female?
Your date of birth   Year 
Capital sum to be insured
Weekly benefit (for Injury) $ 
Weekly benefit (for Sickness) $ 
How many days excess would you like?
Have you previously been insured for this risk?


Enter Validation Code

Disability Due to an Accident Claims
Claims Advice

If you have suffered a disability that is due to an Accident or Injury and you wish to make a claim for benefits you will need to submit the following;
  • Fully complete and sign a claim form.
  • The Attending Physicians Statement must be fully completed and signed by Your regular or treating doctor. You may also attach additional medical certificates to your claim form.
  • If your claim involves the payment of a weekly benefit you must also provide documentation to support your weekly earnings. This may be;
    • A copy of Your weekly pay slip if You are employed by someone else, or
    • You may have Your Company's payroll officer complete and sign the relevant section of the claim form, or
    • If You are self-employed You must provide a copy of Your most recent personal income tax return or assessment. This may also be supplemented with copies of any relevant 'profit and loss' statements.
Accident & Health may appoint a claims assessor to assist with the collection of any further information that may be required.


Disability Due to Sickness Claims
Claims Advice

If you have suffered a disability that is due to an Accident or Injury and you wish to make a claim for benefits you will need to submit the following;
  • Fully complete and sign a claim form.
  • The Attending Physicians Statement must be fully completed and signed by Your regular or treating doctor. You may also attach additional medical certificates to your claim form.
  • If your claim involves the payment of a weekly benefit you must also provide documentation to support your weekly earnings. This may be;
    • A copy of Your weekly pay slip if You are employed by someone else, or
    • You may have Your Company's payroll officer complete and sign the relevant section of the claim form, or
    • If You are self-employed You must provide a copy of Your most recent personal income tax return or assessment. This may also be supplemented with copies of any relevant 'profit and loss' statements.
Accident & Health may appoint a claims assessor to assist with the collection of any further information that may be required.


Claims in Respect of Death - Personal Accident policy claims only
Claims Advice

If you are making a claim on behalf of a deceased person or their Estate, you will be required to submit the following documentation:
  • A copy of a Police report if the Police were summoned to the event.
  • A copy of the Coroners report if undertaken, or written confirmation that a Coroner dispensed with the requirement to conduct an investigation.
  • A copy of the Death Certificate.
Important Information:
If any benefits are payable it is important to clearly nominate the Payee on the claim form. For example:
  • Spouse
  • The Estate
  • The name of any appointed trustee
Accident & Health may appoint a claims assessor to assist with the collection of any further information that may be required.



DECLARATION

By pressing the 'Send Questionnaire' button, we declare that to the best of my/our knowledge and belief the above statements and particulars are true and correct.