Travel Insurance Claim Form - Loss Of Income - Budget Direct Travel Insurance Page 2
Download a blank fillable Travel Insurance Claim Form - Loss Of Income - Budget Direct Travel Insurance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Travel Insurance Claim Form - Loss Of Income - Budget Direct Travel Insurance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Travel Insurance Claim Form | Loss of Income
This must be completed by the injured person’s employer, or if self employed, by an accountant. This form is to verify the loss of income of a person whose illness / injury /
death has given rise to the claim. Any charge made for the completion of this form is the responsibility of the insured and is not refundable under the insurance policy. Please
ensure the employer answers all relevant questions. Ticks, dashes, N/A etc will not be acceptable. This information will be treated as private and confidential.
Employee Details
Title (Mr / Mrs etc)
First Name
Surname
Date of Birth
/
/
Home Address
Home Phone
Work Phone
Mobile
State
Postcode
Email
Employment Details
(as at date of incident)
If the injured person was self employed you do not have to complete this section. Go to ‘Employer or Accountant details’ below.
Place of employment
Date employment commenced
Date employment would have ceased
/
/
/
/
Description of duties
Employee’s normal working hours (include regular and continuing overtime)
Days per week
Hours per day
Usual start time
Usual finish time
AM
AM
PM
PM
If the employee worked regular overtime, would it have continued if there had not been an accident?
Yes
No
if yes, please provide details:
Employer or Accountant Details
If the injured person was self employed you need to complete this section.
Name / organisation / company name
ABN/ACN
Address
Phone
Email
What is the nature of the business
Is the employee related to the employer?
Yes
No
if yes, please provide details:
Wage Details
What were the usual weekly earnings including overtime, regular bonuses, commission etc of the employee (paid on a regular basis) before the incident
Gross normal earnings
Gross overtime earnings
Other gross earnings
Total gross earnings
Less tax
Total net earnings
What award did the employee work under: Federal
State
Please return this claim form to:
2
Budget Direct Travel Insurance, PO Box 547, Pyrmont NSW 2009
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business