Anz Claim Form For Disability Benefit

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ANZ Credit Card Insurance
Claim Form for Disability Benefit
STATEMENT FROM PERSON INSURED
Claim number
Please send your completed form and attachments to
OnePath General Insurance Pty Limited, GPO Box 4028, Sydney NSW 2001.
If there is insufficient space to provide information, attach additional sheets to this form.
1. DETAILS OF THE INSURED
Title
Mr
Mrs
Ms
Miss
Dr
Other
Family name
Given names
Date of birth
/
/
(dd/mm/yyyy)
Gender
Male
Female
Age
Are you
an Australian Citizen?
a New Zealand citizen?
a permanent resident of Australia?
a holder of a temporary visa?
Visa Class
Address
State
Postcode
Phone
Home
Work
Mobile
Email
Note: Provide your email address to receive information on the progress of your claim by email.
Occupation prior to
injury or illness*
* If not employed for a minimum of 10 hours per week, state ‘Not employed’.
Credit card number
2. INjURy OR ILLNESS DETAILS
Which event are you claiming for? (Please tick the relevant box)
Injury
Illness
Describe the injury or illness. If an injury, state when, where and how it happened.
/
/
Exact date your injury or illness began (dd/mm/yyyy)
Details of the person who witnessed the accident/injury
Name
Address
Phone number
Did the injury or accident occur at work?
Yes
No
(If yes, please attach a copy
After the injury or accident were you required to undergo a breath analysis or blood test?
Yes
No
of the analysis results)
00
00
0000
/
/
Date you first received advice or treatment for the injury or illness (dd/mm/yyyy)
/
/
Your first day absent from work (dd/mm/yyyy)
OnePath General Insurance Pty Limited ABN 56 072 892 365.
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