Fillable Anz Claim Form For Disability Benefit (Page 3 of 5) in pdf

Anz Claim Form For Disability Benefit Page 3

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ANZ Credit Card Insurance

Claim Form for Disability Benefit

3. DECLARATION

I authorise any hospital, physician, previous employer, accountant or other person who has attended me or has information relevant to

my claim to supply OnePath General Insurance Pty Limited or its representatives, with any and all information that it may require in the

consideration of this claim. I agree that a photocopy of this authorisation shall be considered as effective and valid as the original.

I declare that the information supplied on this form and in any attached documentation is correct and that I have not withheld anything

material from OnePath General Insurance Pty Limited. I understand that if I do not give full particulars or provide incorrect information, my

rights to obtain benefits under the policy may be prejudiced. I acknowledge that I have been provided with a copy of OnePath’s Privacy Policy

which is also available at OnePath’s website.

OnePath values your privacy and information security. Please be aware that email is not a secure method of communication and there are

risks with using email to send information. If you wish to email your claim form to us, we encourage you to consider encrypting it. For more

information please contact us.

Full name

Signature

Date (dd/mm/yyyy)

4. FURTHER INFORMATION

If you have any questions, please call 13 16 14.

The completed form should be mailed to:

OnePath General Insurance Pty Limited

GPO Box 4028

Sydney NSW 2001

Or emailed to:

.au

or faxed to

02 9234 5015

After reviewing this completed claim form, the Claims Department will contact you to advise if any further information is needed. You may be

required to arrange a report from your doctor.

Please ensure you provide all the requirements listed in our letter in order to avoid any delays with the assessment of the claim

5. THIS SECTION TO BE COMPLETED By yOUR EMPLOyER

(If you are self-employed you can complete this section yourself. If you are not working, proceed to section 6)

Name of employee

Position held

Company name

ABN

Is this person still

employed?

Yes

If no, please provide last date of employment (dd/mm/yyyy)

Date employment commenced (dd/mm/yyyy)

Last date employee worked (dd/mm/yyyy)

Basis under which this person is or was employed. Please tick (✔)

Permanent (part time or full time)

Casual

Temporary/Contract

Self-employed

Average number of hours per week the employee worked in the 90 days prior to the injury or illness

Hours

Name of the employer

or authorised

representative

Position held

Telephone number

Name of employer

Signature of employer

Date (dd/mm/yyyy)

OnePath General Insurance Pty Limited ABN 56 072 892 365.

Page 3 of 5

Anz Claim Form For Disability Benefit Page 3

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