Fillable Anz Claim Form For Disability Benefit (Page 4 of 5) in pdf

Anz Claim Form For Disability Benefit Page 4

Download a blank fillable Anz Claim Form For Disability Benefit 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 Anz Claim Form For Disability Benefit 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.

ANZ Credit Card Insurance

Claim Form for Disability Benefit

6. THIS SECTION TO BE COMPLETED By yOUR MEDICAL PRACTITIONER

This is to certify that

as a result of an injury or illness that occurred on

Please state fully the nature of the injury or illness.

(Please note: any fees charged by the medical practitioner for completion of this certificate are the patient’s responsibility)

Please only select either A or B or C then proceed with completing the remaining part of the form

Unable to resume employment (If you patient was engaged in an occupation at the time of injury/illness)

Is unable to attend their usual occupation of

from (dd/mm/yyyy)

to (dd/mm/yyyy)

Loss of independent existence (If you patient was NOT engaged in an occupation at the time of injury/illness)

Is totally unable to perform at least two of the five activities listed below of daily living without the assistance of another adult

person.

Please indicate 3 the activities of daily living that the insured is totally unable to perform because of injury or illness

bathing and/or showering

dressing and undressing

eating and drinking

using a toilet to maintain personal hygiene

getting in and out of bed, a chair or wheelchair, or moving from place

to place by walking, wheelchair or with the assistance of a walking aid

from (dd/mm/yyyy)

to (dd/mm/yyyy)

Cognitive loss

is suffering from total deterioration or loss of intellectual capacity that requires him/her to be under continuous care and

supervision by another adult person

from (dd/mm/yyyy)

to (dd/mm/yyyy)

Is this illness or injury a result of a work place accident?

Yes

Is this illness or injury in any way associated with:

Pregnancy

Yes

Alcohol

Yes

Drugs

Yes

If ‘yes’, any remarks:

Date this patient first consulted you for this condition (dd/mm/yyyy)

Date of first attendance at this surgery (for any condition) (dd/mm/yyyy)

Has the patient been hospitalised at any time for this illness or injury?

Yes

No If ‘yes’, please provide details below

OnePath General Insurance Pty Limited ABN 56 072 892 365.

Page 4 of 5

Anz Claim Form For Disability Benefit Page 4

Related Articles

Related forms

Related Categories