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Attending Specialist's Statement - Life Insurance
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Attending Specialist's Statement - Life Insurance
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Attending Specialist's Statement - Life Insurance
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Attending Specialist's Statement - Life Insurance
Fields marked with * are required
This form is to be completed by the attending medical specialist 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 the patient. TAL Life Limited will not be responsible for any costs associated with the completion of this form.

Patient's details

Attending Specialist's Statement - Life Insurance
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Patient's name

Date of birth

Medical details

Attending Specialist's Statement - Life Insurance
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Medical details

Are you the patient’s general practitioner? *
Who made the initial diagnosis and on what date?
Has your patient ever experienced these, or similar, symptoms previously?
Based on diagnostic criteria, is your patient suffering from a terminal illness?
Is it expected to result in their death within 12 months?
Is it expected to result in their death within 24 months?

Test results

Attending Specialist's Statement - Life Insurance
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Test results

Please attach copies of the relevant test results.
File:
Clinical notes
File:

Lodge form

Attending Specialist's Statement - Life Insurance
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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

Specialist

Attendant's Contact Details

Signature

I certify that I have examined the patient and that all statements made in this form are correct.
Please provide a signature
Signature
Call
Reference Code
Been here before?
Change of mind?
Fields marked with * are required
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