Claim Form For Unemployment Benefit - Eecu printable pdf download

Level 10, 345 George Street, Sydney NSW 2000. GPO Box 1276 Sydney 2001

Phone: (02) 9295 5555 or from outside Sydney Metro area Freecall: 1800 226 122

Claim Form

FOR unemplOyment BeneFit

CheCklist

Prior to forwarding your claim to the address above, please ensure you have:

answered all the questions

Provided with this claim form a copy of your Employment

Had Centrelink or your Job Network Agency

Separation Certificate or any other documentation

complete the relevant section

submitted to Centrelink or your Job Network Agency

Signed and dated the claim form

Completed all declarations on page 3

Please be advised that we will be unable to assess your claim if all requested information is not provided.

pRivaCy OF inFORmatiOn

What information we collect

The forms we require you to complete to make a claim only ask you for information that is necessary for us to assess your claim.

We may also obtain personal information on you from any other forms you complete, from a third party who provides information

with your consent, or from your Financial institution. The information we obtain from these third parties may include your past

employment history, as it may impact on the claim being assessed.

if you don’t give us the information

if you do not give us all the information requested, we may not be able to process your claim.

how we use the information

We use the information we collect on you to assess your entitlement to benefits in respect of any claim submitted.

Disclosures

We will only disclose information about you to a third party if we need to in order to process, investigate and assess any claims.

The parties to whom we disclose your information include:

• Reinsurers, Loss assessors and investigators, Legal Counsel, and External complaints and dispute resolution bodies.

We may also disclose information about you to a third party if required by law. Your Financial institution may keep a copy of any

forms or information you provide to us through their office.

access to information

You are entitled to access your personal information, except in some limited circumstances outlined in the Privacy Act 1988 (Cth).

You can request access to your personal information by writing to us.

privacy enquiries or complaints

We have internal procedures in place to ensure that any concerns you may have relating to privacy of your information are resolved

promptly, including access to our internal Dispute resolution Panel. if we are unable to resolve your complaint internally, you can

direct your complaint to the Director, Compliance, office of Federal Privacy Commissioner, either on 1300 363 992 or by mail to

GPO Box 5218, Sydney NSW 2001.

Please ask us if you have any queries on what personal information we collect or how it will be used. a copy of our Privacy Policy is

available on request.

peRsOnal Details

Full Name Mr/Mrs/Miss/Ms/Other:

Date of Birth:

address:

Postcode:

Complete telephone number:

Policy Number:

Name of Financial Institution:

Membership Number:

QM3087-0412

Claim Form For Unemployment Benefit - Eecu

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