Anz Claim Form For Disability Benefit Page 2

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ANZ Credit Card Insurance
Claim Form for Disability Benefit
Have you ever had this, or a similar injury or illness in the past?
Yes
No
N/A
If yes, please provide details of the nature of the injury or illness and when it occurred
Please advise who treated you and the date that treatment occurred
/
/
Have you returned to work after the injury or illness?
Yes
No
N/A
/
/
If yes, date you returned to work (dd/mm/yyyy)
00
00
0000
/
/
If still totally disabled, when do you expect your disability to end? (dd/mm/yyyy)
Name and address of doctors or other health professional who first treated/are treating you for this injury or illness
Provider 1
Name
Address
/
/
Date consulted
Type of treatment
Provider 2
Name
Address
/
/
Date consulted
Type of treatment
If you were admitted to hospital, or treated as an outpatient, please give details below.
Provider 1
Name of hospital
Address
/
/
Date admitted
Type of treatment
Provider 2
Name
Address
/
/
Date consulted
Type of treatment
Details of usual general ‘practitioner (‘family doctor’)
Name
Address
Phone number
Length of time you have been attending this doctor
years
months
OnePath General Insurance Pty Limited ABN 56 072 892 365.
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