Australian Insurance Solutions Pty Limited trading as Golfpac Underwriting
ABN 64 088 550 074
License No. 246939
PO Box 2812, Burleigh DC
QLD
4220
Ph: 07 5576 4333 | fax: 07 5576 4338 | e: admin@aisgc.com
GOLFPAC PERSONAL INJURY CLAIM
FORM
FOR MEMBERS PERSONAL ACCIDENT OR INJURY
INCLUDING VOLUNTARY WORKERS
The Issue of this Form is not an Admission of Liability by
Insurers
Policy # :
Claim # :
Please complete and return this claim form as soon as possible, so that your claim will
receive prompt consideration by the Insurers.
THE INSURED
Name of Golf Club
_________________________________________________
GST Number
_________________________________________________
Address of Golf Club
Post Code
Phone
Private
Business
Fax No.
Mobile
Email
Contact Name
Page 1 of 6
DETAILS OF INJURED PERSON
1.
(a) What is your usual occupation?………………………………………………
Date employment commenced?….../….../…...
(b) I, am / am not an Australian citizen or permanent resident. ( *cross out which is not
applicable)
(c) Please list all of the duties of your usual occupation:
………………………………………………………………….…………….….……….…
…………………………………….………………………………………………………...
………………………………………………………………………………….………...…
…………………….…………………...................................................................................
(d) Are you engaged in other activities for which you receive an income?
……………………………………………………..………………………………………..
(e)Name of other employers / principals (if any). ………………………………………….
(f)Average weekly income $……….
2.
Can compensation in relation to the relevant disability be claimed:
(a)From any other Insurance Company? (a) Yes..… No..... Name. ………….……………
(b) under a Worker’s Compensation Scheme? (b). ……………………
(c)Claim Number (if applicable). ………………………….
(d) under any other State or Commonwealth law which provides a weekly benefit?
If "yes” state i) name of company or department.
…………………………………………………….………………………………………..
ii) amount of weekly compensation
$…..……………………………….………………….………………..…………………...
(e) any Transport Accident Compensation Scheme? (d).
.………………………………………………………………..
(f) are you receiving Centrelink payments? (e) ………………………
Weekly Amount $……………….…….
3.
(a) Name of doctor first consulted for the relevant disability?
…………….……………………………………………………
(b) Date of this first consultation? ……/…...../…….
(c) Names & address of other doctors consulted?
………………………………………………..………………….
…………………………………………………………....………
4
(a) Name and address of your usual medical practitioner
………………………………..….…………………..………
…………………………………………………………….....
Page 2 of 6
5
(a) Nature of your sickness
………………………………………..…………………….........
…………………………………..……………..………………...
(b) On what date did symptoms first occur? …………/…………/…………
(c) Are you still being treated for this sickness? Yes …… No …....
(d) Have you previously suffered from the same
or a similar sickness? …………………………………………….………………..…..
If “yes” state;
i) date of each occurrence ………………………………….………...….……...
ii) period of any disability resulting from sickness
…………………………………………….…..…….
(e) Have you been advised to have any surgical Yes ….... No …....
operation in connection with the present sickness?
If “yes” stat;
i) nature of operation
………………………………………..………..…….
ii) date performed/proposed ……………………………………………………....
(f) Have you been wholly and continuously prevented from engaging in
your usual occupation as the sole result of this sickness?
(we refer to this as “TOTALLY disabled” below). Yes …... No …...
If "yes” state dates. From ..…/ ..…/….. . to ...…/ ..…/ ..….
(g) If you are still TOTALLY disabled when do you expect to perform SOME part of
your usual occupation or other
occupation for which you are reasonably qualified by experience, education or training?
…. .../.…..../……….
Please COMPLETE if disability is due to an INJURY
(a) Date and time of your injury ..…..../……. ../…..…... at …….……. ..o'clock am / pm
(b) Were you at work at the time of the injury? Yes ……. or No……..
(c) Where did the injury occur? ( full address)
……………………………………………………………....…..
(d) How did the injury happen?
………………………………………………………….…..…..
(e) What caused it? …………………………………….…….………………..…….
(f) Describe the injuries you received
…………………………………………...…………………..….
………………………………………….……………….…..….
(g) Was an ambulance called? ……………..
(h) Did the police attend?……………….
(i) When did you first seek treatment for this injury? Date:………/………/……….
(j) Have you previously suffered the same or similar injury? Yes …… or No .……
date…../..…/…..
Page 3 of 6
(k) Are there any witnesses to the injury? Yes …… or No ….…
Name(s)…………………………………………………………………
Address…………………………………..…………….………….…….
(l) How long have you been wholly and continuously prevented from engaging in your
usual occupation as a sole result of
this injury (we refer to “wholly and continuously” as “TOTALLY disabled” bellow).
From …../… ../….…to … ./… ../……… inclusive
(m) How long have you been PARTIALLY incapacitated
from engaging in the duties of your usual occupation?
From .…./… ./…… to …./… ../………..inclusive
(n) Describe fully the daily duties of your usual occupation you
cannot perform whilst PARTIALLY incapacitated?
……………………………………….…………..……………
………………………………………………………………..
(o) How many hours per week are you able to work
whilst PARTIALLY incapacitated?
………………………………………………….………………
(p) If you are still TOTALLY incapacitated when do you expect to perform SOME part
of your usual occupation or other
occupation for which you are reasonably qualified by experience, education or training?
……../….…./.…... ..
To be completed by your EMPLOYER (*cross out that which is not applicable)
I HEREBY CERTIFY that ……………………………….has been unable to attend
their usual occupation with the company as a result of * injuries / sickness from
……..../….…../.….…. inclusive.
They have been incapacitated since ……../……../…..... and are expected to resume duties
on ..…../…...../….….
Their average weekly gross pre income tax personal exertion earnings including
commission, overtime, bonuses, shift work payments during the period of six (6) months
immediately preceding the commencement of disability or over a shorter period as they
have been employed $…………….…......…. p/week. (please provide printout of relevant
pay history)
They are employed as *contractor / casual / permanent employee / permanent part time
They are eligible to access this Group Injury and Sickness cover.
They commenced employment or the relevant activities for *me /
upon:……………………………………..…………………….
During the period of incapacity they *received / are receiving
$………….…..……….p/week Workers Compensation Payments.
(if applicable please provide copy of Workers Compensation insurer’s documentation
showing payments received and liability
acceptance notice, claim number)
Page 4 of 6
The organization’s Work cover Insurer is
……………………………………………………………………………and the claimant
is
*eligible / not eligible to access this cover.
*I / We are not aware of any other benefits that they are receiving as a result of the
incapacity or if we are they are specified
below:
………………………………………………………………………………………………
Company name:
………………………………………………………………………………………………
Address:……………………………………………………………………………………
………………………….……….…………………………………………………………
Certified on behalf of the Insured by:
Signature of Paymaster /
Administrator:……………………………………………………Date….…/….…/….....
Name of Paymaster / Administrator:
……………..…………………………………..Telephone…………………………
IMPORTANT REQUEST FOR SUPPORTING DOCUMENTATION:
In order to avoid unnecessary delay in processing your claim, it is important that you
attach the appropriate documentation to support your claim:
 MEDICAL CERTIFICATES AND OUT OF POCKET EXPENSES:
– copies of the medical certificates along with copies of the out of pocket bills
recieved, quotations for recommended procedures etc…
 CONFIRMATION OF INCOME:
– if your claim is for loss of income sustained as a result of your injury you will
need to attached copies of your recent payslips and your last tax return to
substantiate your claim.
Page 5 of 6
PRIVACY
The Privacy Act 1988 requires us to tell you that we as broker and the insurer collect your
personal and sensitive information in order to calculate your loss and entitlements,
determine the insurer's liability, compile data and handle claims.
When handling claims we and the insurer may have to disclose your personal and other
information to third parties such as other insurers, reinsurers, loss adjusters, external claims
data collectors, investigators and agents, or other parties as required by law.
Where you give us information about other persons you must have their consent to this and
provide it on their behalf. If not, you must tell us.
You have the right to seek access to your personal information and to correct it at any time.
Please contact us to advise if any changes are required.
DISPUTE RESOLUTION
Disputes are not an everyday occurrence. However insurers provide an internal dispute
resolution process should any dispute arise. Please feel free to ask for details.
If you are not satisfied with the outcome of that process, we will advise you how to contact
the insurance industry's external independent complaints scheme (subject to eligibility).
DECLARATION
I/We the insured do solemnly and sincerely declare that I/We have complied with the
conditions and warranties (if any) of the policy and in no matter deliberately caused the
said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation
and that the information shown on the form is true and the I/We have not concealed any
information relating to this claim. I/We understand that this claim may be refused if the
information is untrue, inaccurate or concealed.
Further it is understood and agreed that if any property claimed for is subsequently
recovered in an undamaged condition I/We will immediately refund the company any sum
which may have been paid to me/us in respect to such property. In the event of any
property being recovered in damaged condition I/We will immediately hand the same over
to the company for disposal as may be agreed.
I/We acknowledge that I/we have read and understood the Privacy Act information
referred to above and consent to the collection, storage, use and disclosure of personal and
sensitive information of all persons affected by this claim.
I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive
information, then the broker and the insurer will be unable to process my/our claim.
Insured’s Signature
Date
Position Held
_________
Page 6 of 6