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Income Protection Initial Claim Form
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Income Protection Initial Claim Form
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Income Protection Initial Claim Form
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This form is to be completed by the Member and relates to a claim for:
This form will take approximately 20-30 minutes to complete.
This form is to be completed by or in the presence of the person who is making the claim.

Please answer all questions to the best of your ability to ensure that your claim is assessed as quickly as possible.

You can save the form at any time, should you not have these documents readily available.

This form should be completed in full as assessment of this claim may be delayed if the information provided is incomplete.
Before you submit this form, you will need to complete the following: Answer all questions fully Acknowledge the Information Authority Acknowledge the Privacy Disclosure Complete an electronic identity check or attach a certified copy of your proof of age, e.g. a certified copy of your driver’s licence or passport. Provide a copy of your hospital discharge summary (if applicable) Attach copies of reports received from specialists, other treating doctors and health professionals you may have Provide any other information we have specifically requested

Your details

Income Protection Initial Claim Form
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Your policy

Personal details

Date of birth

Contacting you

Your claim

Income Protection Initial Claim Form
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Claim details

Are you receiving or eligible to receive any benefits from any other organisation, insurer or government body? For example: Centrelink, DVA, CTP, workers compensation.

Organisation

Your doctor

Income Protection Initial Claim Form
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Your doctor

What is the name of the doctor you have been consulting for your illness or injury?

How long have you been a patient of this doctor?

Have any other doctors, specialists or healthcare providers been consulted?

Practitioner

Your job

Income Protection Initial Claim Form
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Your job

Are you self-employed?

Return to work

Have you returned to work in any capacity since the date you stopped all work due your illness or injury?

Additional information

Income Protection Initial Claim Form
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Additional information

Online identity verification

Income Protection Initial Claim Form
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You need to provide ID documents for us to perform online ID verification. How would you like us to verify you?
You will be prompted to attach a copy of your driving licence and medicare in the next page.
Please select the ID type you wish to use for online ID verification
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Process Identity Documents

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Identity was not confirmed
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Supporting documentation

Income Protection Initial Claim Form
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Certified copy of proof of age
File:
Copies of all medical reports
File:
Resume
File:
Completed Tax File Number Declaration form
File:
Copies of pay slips since returning to work
File:

Important information

Income Protection Initial Claim Form
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Information authority

I hereby authorise any doctor, hospital, therapist or other medical professional who has attended me, to release to TAL Life Limited (TAL), its related bodies corporate, its agents or its representatives and to my superannuation fund or its administrator, information relevant to my policy and/or claim, with respect to any illness or injury, medical history, consultations, medications or treatment, received by me together with copies of any and all medical records. I consent to TAL and my superannuation fund collecting this sensitive information.
I authorise any insurer (including workers compensation/CTP insurer), government agency or body (including Centrelink/ Department of Veterans’ Affairs), employer, accountant or other relevant holder of information, to release to TAL Life Limited, its related bodies corporate, its agents or its representatives and my superannuation fund or its administrator, information which they require for the purpose of assessing or investigating my claim.
A copy of this authority is to be regarded as if it were the original signed authority.

Privacy disclosure

The Privacy of TAL customers is important and TAL is bound by obligations imposed by current privacy laws including the Australian Privacy Principles. The way in which TAL collects, uses, secures and discloses your personal information is set out in the TAL Privacy Policy available at http://www.tal.com.au/Privacy-Policy or free of charge on request to TAL using the contact details below.
GPO Box 5380, Sydney NSW 2001
Telephone: 1300 209 088
Fax: 1800 300 072
Email: customerservice@tal.com.au

Collection and use of personal information

We are bound by relevant legislation including the Privacy Act 1988 (Cth) and the 13 Australian Privacy Principles when we collect, store, use and disclose your personal and sensitive information (“personal information”).

During your claim we may collect personal information, including your name, age, gender, contact details, health information, lifestyle information, financial information, and employment information. If you do not supply the information that is required, we may not be able to provide our services to you and this may result in us being unable to continue to assess or pay a claim. In some circumstances we may take steps to verify the information we collect about you from independent sources to ensure the information is correct, up to date and complete.

Disclosure of personal information

Where we consider it appropriate during your claim, we may disclose relevant personal information to related bodies corporate and external individuals and organisations and entities including but not limited to:

providers of medical and health services; reinsurers, other insurers and their administrators; any person acting on your behalf, including your financial adviser, solicitor, accountant, executor, administrator, trustee, guardian or attorney; for members of superannuation funds where TAL is the insurer, to the trustee, or administrator of the superannuation fund as the superannuation fund owns the life insurance policy on your behalf and where appropriate to your employer for the purposes of rehabilitation assistance for return to work; and providers of services to whom TAL outsources certain functions such as medical providers, rehabilitation providers and surveillance/investigation providers.
Where it is required or authorised by law we may also need to disclose information about you to Government agencies and Courts and enforcement bodies (e.g. under Court Orders or Statutory Notices).

Generally you have a right to access information we hold about you with limited exceptions and if you wish to access information we hold about you please contact us.

We are legally required to send all communications about your policy to the policy owner. However, where the policy owner is different from the life insured, we will not communicate personal medical information about a life insured to a policy owner unless the life insured has consented or there is other lawful authority.
By signing this form you consent to us collecting, using and disclosing your personal and sensitive information as detailed in our Privacy Policy at http://www.tal.com.au/Privacy-Policy and as summarised above.

Please note that this authority remains valid for the duration of your claim.

Declaration

Income Protection Initial Claim Form
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that the information in this claim form is true, complete and correct. I understand and agree that if I make any false or fraudulent statements or fail to advise TAL Life Limited of any relevant information regarding my claim, TAL Life Limited may refuse to pay this claim or cencel my policy.
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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