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Attending Doctor's Statement - Life Insurance
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Attending Doctor's Statement - Life Insurance
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General enquiries
Attending Doctor's Statement - Life Insurance
Phone
1300 660 027
8.00am to 5.00pm (AEST) weekdays
Email
super@vissf.com.au
Address
GPO Box 4974
Melbourne VIC 3001
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Attending Doctor's Statement
Tracking Code:
TALGRC005 VISSF Intent to Claim Attending Doctors Statement
Intent to Claim Life Insurance
Attending Doctor's Statement
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Attending Doctor's Statement - Life Insurance
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Attending Doctor's Statement - Life Insurance
Fields marked with
*
are required
This form is to be completed by the attending medical doctor and relates to a claim for Life Insurance
Important note
If there is a charge for completing this form, the payment is the responsibility of your patient. TAL Life Limited will not be responsible for any costs associated with the completion of this form.
Patient's details
Attending Doctor's Statement - Life Insurance
Fields marked with
*
are required
Patient's name
Title
*
Mr
Mrs
Miss
Ms
Other
Other
Given name(s)
*
Surname
*
Personal details
Date of birth
Day
*
Month
*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
*
Medical details
Attending Doctor's Statement - Life Insurance
Fields marked with
*
are required
Medical details
Are you the patient’s usual general practitioner?
*
Yes
No
What date did you begin treating your patient?
*
Who referred your patient to you?
*
On what date did you first see them?
*
What is the current diagnosis?
*
Please provide diagnostic evidence confirming the diagnosis
*
Who made the initial diagnosis and on what date?
Doctor's name
*
Specialty
*
Date
*
Has your patient ever experienced these, or similar, symptoms previously?
Yes
No
Please provide the date
*
Based on diagnostic criteria, is your patient suffering from a terminal illness?
Yes
No
Please provide the date your patient was diagnosed as terminally ill
*
Please confirm your patient's life expectancy
*
Is it expected to result in their death within 12 months?
Yes
No
Is it expected to result in their death within 24 months?
Yes
No
Test results
Attending Doctor's Statement - Life Insurance
Fields marked with
*
are required
Test results
Please attach copies of the relevant test results.
Download Attachment
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File:
Clinical notes
Download Attachment
Click to upload
File:
Lodge form
Attending Doctor's Statement - Life Insurance
Fields marked with
*
are required
Privacy statement
TAL Life Limited is bound by obligations imposed by current privacy legislation. Information received or requested from you is handled in accordance with these obligations. TAL Life Limited requires that all entities adhere to relevant privacy obligations when dealing with personal and sensitive information about our customers.
Medical attendant
Name of Medical Attendant
*
Specialist
Yes
No
Specialty
*
Attendant's contact details
Address
Address Line 1
*
Address Line 2
Level Number
Unit Number
Street Number
Street Name
Street Type
ACCESS
ALLEY
ALLEYWAY
AMBLE
ANCHORAGE
APPROACH
ARCADE
ARTERY
AVENUE
BASIN
BEACH
BRIDGE
BROADWAY
BEND
BLOCK
BRAE
BRACE
BREAK
BROW
BOULEVARD
BYPASS
BYWAY
CAUSEWAY
CIRCUIT
CUL-DE-SAC
CHASE
CIRCLE
CLOSE
COLONNADE
CIRCLET
COMMON
CORNER
CENTREWAY
CONCOURSE
COVE
CROSSWAY
COPSE
CIRCUS
CROSSROAD
CRESCENT
CROSSING
CROSS
CREST
CORSO
COURT
CENTRE
CUTTING
COURTYARD
CRUISEWAY
DALE
DELL
DEVIATION
DIP
DRIVE
DRIVEWAY
DISTRIBUTOR
EDGE
ELBOW
END
ENTRANCE
ESPLANADE
ESTATE
EXPRESSWAY
EXTENSION
FAIRWAY
FIRETRAIL
FLAT
FOLLOW
FORMATION
FRONT
FRONTAGE
FORESHORE
FIRE TRACK
FOOTWAY
FREEWAY
GAP
GARDEN
GARDENS
GLADE
GLEN
GULLY
GROVE
GRANGE
GREEN
GROUND
GATE
GATES
HILL
HIGHROAD
HEIGHTS
HIGHWAY
INTERCHANGE
INTERSECTION
JUNCTION
KEY
LANE
LANDING
LEES
LINE
LINK
LOOKOUT
LANEWAY
LOOP
LITTLE
LOWER
MALL
MEW
MEWS
MEANDER
MOUNT
MOTORWAY
NOOK
OUTLOOK
PARK
PART
PASS
PATH
PARADE
PATHWAY
PIAZZA
PARKLANDS
POCKET
PARKWAY
PLACE
PLATEAU
PLAZA
POINT
PORT
PROMENADE
PASSAGE
QUADRANGLE
QUADRANT
QUAD
QUAY
QUAYS
RAMP
REACH
ROAD
RIDGE
ROADS
ROADSIDE
ROADWAY
RESERVE
REST
RIDGEWAY
RIDE
RING
RISE
RAMB
RAMBL
RAMBLE
RMBL
RND
ROUND
RNDE
RONDE
RANGE
RNGE
ROW
RIGHT OF WAY
ROSEBOWL
ROUTE
RETREAT
ROTARY
RUE
RUN
RIVER
RIVIERA
RIVERWAY
SUBWAY
SIDING
STATE HIGHWAY
SLOPE
SOUND
SPUR
SQUARE
STREET
STEPS
STRAND
STRIP
STAIRS
SERVICE WAY
TARN
TERRACE
THOROUGHFARE
TRUNKWAY
TOLLWAY
TOP
TOR
TRIANGLE
TRACK
TRAIL
TRAILER
TURN
TOWERS
UNDERPASS
UPPER
VALE
VIADUCT
VIEW
VILLAS
VISTA
WADE
WALK
WAY
WHARF
WALKWAY
WYND
YARD
Suburb
State
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Selected Address Field
Work phone number
*
Email address
*
Signature
I certify that I have examined the patient and that all statements made in this form are correct.
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Date
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