DISABILITY CLAIMANT’S STATEMENT - Liberty Claim Form.pdf · Liberty Group Limited – an...

Liberty Group Limited – an Authorised Financial Services Provider Liberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001 PO Box 10499, Johannesburg, 2000 Contact Centre number: 0860 456 789 / +27 (0)11 408 4871 E-mail address: [email protected] Fax No.: (011) 408 2005

Please note that in the event of any modification or variation of this standard form Liberty will regard this form as being invalid and of no force and effect. Do not sign blank or incomplete forms.

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DISABILITY CLAIMANT’S STATEMENT

We are required to share, collect and process your Personal Information (PI). Your PI is collected and processed by our staff, representatives or sub-contractors and we make every effort to protect and secure your PI. You are entitled at any time to request access to the information Liberty has collected, processed and shared.

REQUIREMENTS

Please take careful note of the compulsary requirements when claiming:

Copy of Declaration by Employer for consideration of a disability claim form. Copy of Medical Certificates for Disability form completed by doctor that is treating the assured for the illness If assured is claiming under Overhead Expenses Benefit (OEB) or an Income Protection policy we require the last audited account of the

business as an additional requirement.

Liberty reserves the right to call for additional requirements where deemed necessary

The contact person for this claim is:

Name Branch

Email address Cell no.

Tel no. Fax no.

NB: Claims department will send correspondence and copies only where this information has been supplied. In other circumstances, correspondence will be directed to the policyholder/life assured.

(Please tick blocks where appropriate) Benefits Claimed: Disability Impairment Femability Enability Income Disability

Living Lifestyle Absolute Protector Careability Debility Early Retirement

1. PERSONAL STATEMENT BY THE LIFE ASSURED (To be fully completed in all instances)

Policy number(s)

Surname First name Initials

Date of birth: Identity number

Name of Medical Scheme Scheme number

Date joined scheme Hospital file no

Tax reference no.

Residential address

Postal address

Contact details: Home Fax

Work Cell

Email

What is the highest academic, professional or trade qualifications?

Have you or the Policyholder/Life Assured ever been insolvent or are any sequestration hearings proceeding, pending or contemplated?

Yes No

Are you a smoker? Yes No

Have you ever been advised to stop smoking? Yes No

Do you consume alcohol? Yes No

Have you ever been advised to stop consuming alcohol? Yes No

Have you ever taken recreational drugs? Yes No

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Name Policy number

2. INFORMATION RELATING TO YOUR MEDICAL CONDITION

a) Medical reasons for claim

b) Medical condition is due to disease/accident:

Date diagnosed/date of event:

c) If the medical condition resulted from an Accident please provide full details?

d) If reported to the police, please provide the police station at which the accident was reported.

e) Case number

f) If reported, we require a copy of the police report.

g) Name, address and phone number of your doctors during the last 5 years:

h) Name, address of all attending doctor/s Hospital/s, Clinic/s including consultations for current condition:

Doctor’s Name Telephone Number Reason for Consultation Date of Consultation

i) What form of treatment are you currently undergoing/medication being taken, please list

3. Living Lifestyle, Femability, Careability, Impairment, Enability Benefits

Please indicate what category you are claiming under:

4. DISABILITY DETAILS: Sections 4 and 5 to be used only when claiming for disability Absolute Protector, Lump Sum Disability benefits, Monthly Income Protection, Waiver Benefits,

5. PARTICULARS OF PRESENT OCCUPATION: (Also applicable to self employed)

a) Name and address of last or present employer:

b) Length of service with employer:

c) What was your full-time occupation immediately before your current disability/impairment began?

d) Breakdown of your duties:

ADMINISTRATIVE % SUPERVISORY % MANUAL % TRAVEL %

e) Give an accurate description of the exact duties and nature of your full time occupation (job description):

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Name Policy number

f) How long have you been following this occupation?

g) What date did you stop working?

h) When do you expect to return to work?

i) State particulars of your current avocations:

j) Have you been offered or enquired about any alternative occupation for remuneration by your employer? Yes No

i) If “Yes” describe duties of alternative occupation offered:

ii) Have you accepted the alternate occupation offered? Yes No

iii) If “Yes” when do you expect to follow the alternative occupation?

On a full time basis: On a part time basis: k) Occupations held in the past 10 years:

NATURE OF OCCUPATION AND EMPLOYER DATE DATE

FROM TO FROM TO FROM TO FROM TO FROM TO FROM TO FROM TO FROM TO FROM TO FROM TO

6. INFORMATION RELATING TO YOUR INCOME (Liberty reserves the right to call for Financial evidence in order to assess the claim)

a) What was your taxable income for the past 12 months?

b) Commission earned during the past 24 months:

c) Directors fees for the past 24 months?

d) Have you received any income or any other benefits since disablement? If “Yes”, please state income amount for every month since disablement, including amounts, dates and source of income?

Yes No

e) Have you claimed or do you intend claiming for payment of disability, dread disease, impairment, or any similar benefits with any other assurance companies? If “Yes” please give details below:

Yes No

NAME OF ASSURANCE CO. POLICY NUMBER DATE OF INCEPTION ESTIMATED VALUE

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Name: Policy number:

6. PAYMENT DETAILS

For your protection payment will only be effected by Electronic Fund Transfer, this will also ensure faster payment. Payment may only be made to the policyholder. Payment can be made to the bank account which is currently paying the premiums subject to the approval of the policyholder. Should bank details differ to the account details on record, please provide proof of account i.e. a copy of a cancelled cheque OR copy of current bank statement on a bank letterhead OR a copy of a printout from the bank with a bank stamp.

NAME OF ACCOUNT HOLDER

NAME OF BANK NAME OF BRANK

BRANCH CODE ACCOUNT TYPE (excluding credit card) ACCOUNT NUMBER

It is most important to give the correct account number, name and spelling of the account to be credited. Liberty will not bear any responsibility for delays or other damage suffered due to incorrect details being provided.

7. DECLARATION

I hereby warrant and declare that the foregoing answers and statements are true to the best of my knowledge and belief, and that I have withheld no material fact from Liberty. I further declare that the condition giving rise to this claim, was not due in any way to self inflicted injury or use of alcohol or drugs of any kind, and that I am not insolvent.

I agree that the written statements and affidavits of all the doctors who attended or treated the Life Assured and all other papers submitted in support of this claim, shall constitute and are hereby made a part of this claim, and further agree that the supply of this form, or any other forms supplemental hereto by Liberty, shall not constitute any admission by it that there is any assurance in force on the life in question or a waiver of any of its rights or defences in law.

I acknowledge and agree that any benefits payable in respect of this claim shall be forfeited if I, or anyone acting on my behalf or with my knowledge or consent, have knowingly withheld any material fact or submitted any false information in respect of this claim. I further agree that upon payment of the benefits hereby claimed, Liberty shall be discharged from all liability in respect of such benefit.

I hereby authorise any medical practitioner, hospital or any other person to furnish to Liberty, or its representative any details relating to any illness or injury to the Life Assured or such other information as may be necessary to consider this claim. I know and understand the confidential nature of medical information. By appending my signatures at the end of this Personal Declaration, I am agreeing that I have given permission to Liberty to obtain medical information and evidence from and / or through third parties without it being seen as a breach of my right of privacy and confidentiality. I further agree that any authorised medical personnel or practitioner may release confidential information to Liberty or other person acting on their behalf and in such manner or method as Liberty may direct.

I indemnify Liberty and its directors, agents and employees against any claim of whatever nature which may be made against them as a result of or arising out of the furnishing of such information. Where the conditions of the policy so allow, I irrevocably authorise Liberty to deduct any expenses incurred by it in respect of this claim and for which I am liable from the benefits payable under the policy. In the event that a claimant is both the life assured and the policyholder of the policy and is incapable of managing his/her own affairs, an appointment of a curator bonis will be required in order for Liberty to further assess the claim.

Signed at this day of 20

Policyholders signature

Life assured’s signature

Liberty Group Limited – an Authorised Financial Services Provider Liberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001 PO Box 10499, Johannesburg, 2000 Contact Centre number: 0860 456 789 / +27 (0)11 408 4871 E-mail address: [email protected] Fax No.: (011) 408 2005


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MEDICAL CERTIFICATE FOR DISABILITY FROM ATTENDING DOCTOR

To: Dr Patient/Claimant details

Address Name

Policy number

Date of birth/ID. no.

Medical aid details: Fund name

Number

Main member

CONFIDENTIALITY NOTICE

This information is intended for the addressee only and may contain confidential and privileged information. If you are not the addressee, the employee or agent thereof you must not take any action based on the information enclosed. If this facsimile is received in error please notify the sender immediately to arrange return at our expense. Note: Please ensure that this report is submitted to the Claims Department only and not to any other party

Dear Doctor We would appreciate your co-operation in providing the information requested in this form. Insurance disability has two components i.e. functional impairment and disability. The assessment of functional impairment rests with various medical experts and is aimed at establishing the degree of impairment of normal functions due to medical, psychiatric or traumatic causes after reasonable treatment. It also involves the duration of the impairment, whether it is of a permanent nature or temporary, and if temporary the likely duration and prognosis. The decision regarding disability is a legal decision taken by the insurance company and is based on details of the claimant, the occupation for which the claimant is insured, the terms and conditions on which the risk was accepted and the policy issued and the medical impairment of the life assured itself. The information requested, is therefore required to assist us in reaching this decision as quickly as possible. I authorise you to disclose to Liberty any information you may have concerning my health and habits. The fee payable for this report is in accordance with Liberty’s medical tariffs. Please do not hesitate to contact us if you require any further information. Thanking you in anticipation. Yours faithfully Liberty Claims Management

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Name Policy number

CLAIMANT’S DETAILS

Full name of claimant

Date of birth

ID number (if known)

Occupation (including description of duties)

Hiighest qualification Last day at work

MEDICAL HISTORY

1. Reason for claim

2. Date diagnosed

3. Date symptoms started:

4. Date first seen by you for this reason

5. Date stopped work

6. Date expected to return to work

7. Name of referring doctor

8. Doctor’s contact number

9. Have you seen him/her for any other conditions? (please give dates and details below)

Date Reason for Consultation Treatment Prescribed Duration of Complaint

MEDICAL REFERENCES

Please give the details of any other practitioners, specialists or hospitals to whom the claimant has been referred. Please include copies of all available specialist reports.

Clinic/ Hospital/ Specialist Reason Contact Details

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Name Policy number

MEDICAL HISTORY (CONTINUED)

Please give full medical history, including the following:

Symptoms and diagnosis

Dates of any diagnoses of any other conditions

Clinical details indicating severity and permanence

Relevant test results (eg. lung function readings, X-ray or scan results) etc.

Treatment and response/ Compliance to treatment/How often does he/she require treatment

Other comments

Current major complaint(s)

RESULTS OF MOST RECENT MEDICAL EXAMINATION (We do not require actual examination)

Date of last examination

Please give full clinical details as at that examination, including height, weight, and blood pressure readings. Please include details of any limitations evident at that examination (e.g. joint limitations, visual acuities).

Does the claimant use tobacco in any form? Yes No

If “Yes” please provide details:

Is current medical impairment due to:

a) Previous illness or injury: Yes No

b) The intentional consumption of alcohol, narcotics or any toxic substance: Yes No

c) Attempted suicide or any self inflicted injury: Yes No

d) Taking of drugs other than under the directions of a registered medical practitioner: Yes No

PROGNOSIS

What are chances of recovery (good/fair/poor/nil)?

Are any residual problems likely? Please specify:

If period off work longer than usually expected for recovery for this condition, please give reasons:

Date expected to return to work:

Is this form completed after an examination or from records?

Date of records?

Is he/she able to handle their own financial affairs? Yes No

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Name Policy number

In all instances this form must be completed FUNCTIONAL ABILITIES

Please comment on the member’s ability to carry out the specified activities in the table below. ACTIVITY CURRENT LIMITATIONS EXPECTED FUTURE ABILITY No

Limitation Mild

Limitation Moderate Limitation

Impossible Improve Remain

constant Deteriorate

Shopping: lifting or carry groceries

Grasp

Princer grip

Use of fine co-ordination

Holding Strength

Grip Strength

Standing

Climb stairs

Kneel

Squat

Personal Care i.e grooming, dressing, etc

Bladder status

Bowel status

Visual acuity-with glasses

Light manual labour

Operating light machinery

Operating heavy machinery

Driving a light motor vehicle

Driving a heavy motor vehicle

Work in cramp conditions

Work in dusty environment

Work in a fume environment

Walking(non strenous) over level ground

Walking(strenous) over uneven ground

Rise to standing position unaided

Cognitive Behaviour ie short term memory

Higher Cognitive function

Intellectual function

Memory

Attention

Language function

Visual fields

Mental Behaviour i.e. concentration, moods etc

Interaction with others

Seated/sedentary tasks

Participation in Sports

Participation in Hobbies

General comments, which may clarify the responses in the table. If improvement is expected, please indicate the time period in which that improvement is anticipated.

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Name: Policy number:

TREATMENT AND REHABILITATION

Current medication regime. Please specify all medications and dosages:

Other treatment the claimant has received or is currently receiving (e.g. physiotherapy, occupational therapy, psychotherapy):

Planned future treatment, including surgery:

Your recommendations regarding rehabilitation (if applicable):

Please attach copies of any correspondence received from any practitioners,

specialists or hospitals in respect of the claimant.

Doctor’s details

Name of doctor Practice number Postal address Telephone number Facsimile number Email address Qualifications

I declare that to the best of my belief and knowledge, the information contained in this report is true, accurate and complete and that any information that could influence a decision regarding this claim, has not been withheld. Signature of doctor Date of report

Please supply the following details in order for us to pay your account: Name of bank Account number Branch code

Liberty Group Limited – an Authorised Financial Services Provider Liberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001 PO Box 10499, Johannesburg, 2000 Contact Centre number: 0860 456 789 / +27 (0)11 408 4871 Email address: [email protected] Fax No.: (011) 408 2005


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EMPLOYER’S DECLARATION Please print in block letters and use black pen

IF SELF EMPLOYED, TO BE COMPLETED BY AUDITOR/BOOKKEEPER OR RELEVANT THIRD PARTY

A. PERSONAL PARTICULARS OF EMPLOYEE Policy number/s

Full name of employee

Identity number Date of birth

Medical aid scheme

Membership number Employees tax number

B. PARTICULARS OF OCCUPATION 1. What was his/her full time occupation immediately before his/her disability?

2. Commencement date of occupation

3. Please give a completed and accurate description of the exact duties and nature of his/her full time occupation or enclose a copy of his/her job description.

4. Percentage of time spent engaged in: ADMINISTRATIVE

DUTIES% SUPERVISORY DUTIES

% MANUAL DUTIES % TRAVELLING DUTIES %

5. (a) When was he/she last actively able to perform part of the duties of his/her full time occupation?

(b) Has he/she been medically boarded or was his/her services terminated?

(c) Official boarding date/date services terminated

(d) Reasons for termination

(e) Is he/she still being paid? If No, when was the last time?

(f) Until what date is renumeration expected to be paid?

(g) Anticipated date that the employee will return to work:

(h) Is he/shestill engaged in any part of his/her occupation? Yes No

6. Are you aware if he/she is engaged in any occupation(permanent or part time) after his/her disablement? Yes No

If “Yes”, please provide details, including dates below

Occupation Dates

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Name Policy number

C. INFORMATION REQUIRED WITH REGARDS TO ALTERNATIVE DUTIES 1. Has any consideration been given to the extent to which the employee’s work circumstances or duties might

be adapted to accommodate the employee’s disability needs? If ‘No”, furnish reasons: Yes No

2. If “YES”, in what capacity? 3. In the event of being self employed, please state if business is to continue. Yes No

If “Yes”, please specify the amount still being paid to the life assured: R

D. DETAILS OF FUNCTIONAL INCIDENT/ILLNESS 1. What was the cause of him/her not being able to work?

2. If he/she was injured on duty, please provide us with a short description of the circumstances of the incident/accident:

3. Please supply brief history of sick leave, for 2 years prior to disability, for any absence exeeding 2 days:

Date Details of illness or injury Number of working days absent Doctors consulted

E. INFORMATION ON INCOME 1. What are the details of remuneration for past 12 months? R

Has he/she suffered any loss of income since the illness/injury? Yes No

2. If “Yes”, was income stopped or reduced? If reduced – to how much? R

3. Amount still being paid: R

F. SOURCE OF INCOME 1. Is he/she entitled to a benefit from any other source as a result of the incapacity (e.g. other insurance

policies)? Yes No

2. If “Yes”, please give full details

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Name Policy number

I hereby declare that I am the person designated and authorised by the above-mentioned company to complete and attest to this form and further confirm that all particulars provided hereto are to the best of my belief and knowledge both true and correct. I confirm that no material information, which is relevant to the assessment of this claim has been withheld, concealed or misstated. (In the event of this form being completed by an Auditor or an Accountant details of their practice numbers must be provided.) Name Position/Relationship Company Telephone number. Physical address (or company stamp) Signature Date: / / Employee’s email / website address

Liberty Group Limited – an Authorised Financial Services Provider Liberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001 PO Box 10499, Johannesburg, 2000 Contact Centre number: 0860 456 789 / +27 (0)11 408 4871 Email address: [email protected] Fax No.: (011) 408 2005


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MEMBER INFORMATION FORM (SARS REQUIREMENTS)

“*The South African Revenue Services (SARS) now requires additional information to be included on your tax certificate. In order to avoid delays in processing your request, or penalties imposed by SARS, please complete the following information in full. Pease note all fields required below are mandatory.”

MEMBER INFORMATION

Surname/Entity name Policy number

First two names

Initials Date of birth / /

RSA identity number Income tax number.

Passport no.(if foreigner) or other identity number

Passport or other identity country of issue

Contact email

Home telephone number Fax number

Business telephone no. Cell number

MEMBER PHYSICAL ADDRESS DETAILS - RESIDENTIAL

Complete your residential address

Postal code

MEMBER ADDRESS DETAILS – POSTAL

Mark here with an “X” if same address as above

or complete your postal address

Postal code

MEMBER PHYSICAL ADDRESS DETAILS – BUSINESS / EMPLOYER

Complete your physical business /

employer address

Postal code

Member signature

Date / /

Please fax your forms to (011) 408 2005 alternatively, please email your form to [email protected]

DISABILITY CLAIMANT’S STATEMENT - Liberty Claim Form.pdf · Liberty Group Limited – an...

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