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Attending Doctor's Statement - Life Insurance

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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

super@vissf.com.au

Address

GPO Box 4974
Melbourne VIC 3001

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

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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 *

Other

Given name(s) *

Surname *

Personal details

Date of birth

Day *

Month *

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

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

Please provide the date *

Based on diagnostic criteria, is your patient suffering from a terminal illness?

Yes

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

Is it expected to result in their death within 24 months?

Yes

Test results

Attending Doctor's Statement - Life Insurance

Fields marked with * are required

Test results

Please attach copies of the relevant test results.

File:

Clinical notes

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

Specialty *

Attendant's contact details

Address

Address Line 1 *

Address Line 2

Level Number

Unit Number

Street Number

Street Name

Street Type

Suburb

State

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.

Please provide a signature

Draw signature

Type signature

Signature

ROTATE YOUR
DEVICE FOR
BEST RESULTS

Please type signature *

Date *

Call

Reference Code

Been here before?

Change of mind?

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Insurance is provided by TAL Life Limited ABN 70 050 109 450 AFSL 237848 to VIS Nominees Pty Ltd ABN 11 006 586 367 AFSL 235097 as trustee of The Victorian Independent Schools Superannuation Fund ABN 37 024 873 660

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