Claims Information Form

Thank you for taking the time to complete this form. The information you provide today helps us understand your current circumstances and determine the best course of action for your potential claim.

It will take you approximately 20 minutes to complete and can be saved at any point to complete at a later stage.

To help guide a smooth and efficient claims experience please ensure the information you provide is as accurate as possible.

We will assess your information and contact you to discuss any options you may have.

Personal Details

First Name(s)

Middle Name(s)

Surnames

Residential Address

Street Address

City

State

Postcode

Mailing Address same as residential

YesNo

Mailing Address

Street address

City

State

Postcode

Mobile phone number

Date of Birth

Email Address

Please upload a clear copy of your Drivers License (front and back) or another form of Photo ID *

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Super Fund / Insurance Provider

Member Number / Policy Number

Do you have another super fund? *

YesNoUnsure

Super Fund *

Member Number *

Do you have any other Life / TPD / Trauma or Income Protection cover? *

YesNoUnsure

Please provide details (Type of cover if known, name of Insurer and Policy Number)) *

Condition Details

What is the exact nature of the condition that you are looking to claim for?

Please describe your current symptoms:

Has this condition caused you to stop work?

YesNo

Please describe any other conditions and/or contributing factors that may have contributed to you stopping work?

How has your condition affected your ability to work (driving, sitting at desk, operating machinery, etc.)?

Date of last day at work

Is your condition a result of a workplace incident?

YesNo

Have you lodged a work related claim?

YesNo

Is this work claim finalised?

YesNo

Date of first symptom/injury

Date of first doctor consultation

Date of diagnosis

Have you ever suffered from the same or a similar condition in the past?

YesNo

Please provide details of the diagnosis, treatment and when this occurred:

Please provide details of your USUAL Medical Practioner:

Name

Street Address

City

State

Postcode

Phone Number

Please provide the details of any other health professionals (e.g. Specialist/Hospital/Physio) you have consulted in relation to your current condition besides your GP:

Name of Doctor

Type of Doctor

Please upload additional information including hospital discharge form, imaging and investigations in relation to the condition you are claiming for:

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Please provide details of your treatment plan including medications (dosages), exercise, allied health professional visits, etc:

What improvements have been gained under your current plan?

Has your Doctor made any recommendations for future treatment?

YesNo

Please provide details:

Occupation Details

What was your occupation immediately prior to stopping work?

What date did you start the above role?

How many hours per week did you work prior to stopping work?

Has your doctor indicated you will be capable of returning to work in either full or part-time capacity?

YesNo

Please provide details of when your doctor anticipates your return to part-time, and or, full-time work:

Part-time

Full-time

Have you discussed a return to work with your employer?

YesNo

What suitable/alternative duties can they provide you?

Previous Work History and Education

Please advise what level of education or other qualifications you have attained:

Please describe your previous work history or upload your resume:

Year of employment

Occupation

Employer name

Duties performed

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Earnings

Are/were you self employed?

YesNo

Current financial year to date

Last finacial year

Previous financial year

Employment/Business Income

Investment income

Other sources of income

TOTAL INCOME

Do you know your annual salary?

YesNo

Confirm Annual Salary

Employer Super Amount

Please confirm your take-home earnings

How ofteni.e. weekly, fortnightly, monthly

Since stopping work have you received or do you expect to receive any income or benefits from the following sources:

Employer, or business

YesNo

Income amount (gross)

Frequency (i.e. weekly, fortnightly, monthly)

Date commenced

Lump sum benefits

Workers Compensation

YesNo

Income amount (gross)

Frequency (i.e. weekly, fortnightly, monthly)

Date commenced

Lump sum benefits

Centrelink

YesNo

Income amount (gross)

Frequency (i.e. weekly, fortnightly, monthly)

Date commenced

Lump sum benefits

Another Insurance policy

YesNo

Income amount (gross)

Frequency (i.e. weekly, fortnightly, monthly)

Date commenced

Lump sum benefits

Other

YesNo

Please specify

Income amount (gross)

Frequency (i.e. weekly, fortnightly, monthly)

Date commenced

Lump sum benefits

Please provide copies of payment letters

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Additional Information

If you are aware of any further information that would assist us in the assessment of your claim, please provide that information here or upload a signed and dated additional page(s).

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Declaration

I understand providing the requested information is voluntary and if I choose not to provide this information Keystone Wealth is unable to assess my eligibility to make an insurance claim. I have read the privacy collection notice and I am aware of Keystone Wealth’s Privacy Policy.

Please read the FPAA Financial Services Guide (FSG) dated Version 30th June 2022 for further Information. If you would like an additional copy of the current FSG please ask your Adviser. You can also access the FSG on our website www.keystonewealth.com.au.

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