APPLICATION FOR ADVANCE PAYMENT - Liberty
|DISABILITY CLAIMANT’S STATEMENT |
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|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. |
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|REQUIREMENTS |
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|Please take careful note of the compulsary requirements when claiming: |
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|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. |
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|Liberty reserves the right to call for additional requirements where deemed necessary |
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|The contact person for this claim is: |
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|Name | | |Branch | | |
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|Email address | | |Cell no. | | |
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|Tel no. | | |Fax no. | | |
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|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. |
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|(Please tick blocks where appropriate) |
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|Benefits Claimed: | Disability | Impairment | Femability | Enability | Income Disability |
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| | Living Lifestyle | Absolute Protector | Careability | Debility | Early Retirement |
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|1. |PERSONAL STATEMENT BY THE LIFE ASSURED (To be fully completed in all instances) |
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| |Policy number(s) | | |
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| |Surname | |First name | |Initials | | |
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| |Date of birth: | |Identity number | | |
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| |Name of Medical Scheme | |Scheme number | | |
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| |Date joined scheme | |Hospital file no | | |
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| |Tax reference no. | | | |
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| |Residential address | | |
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| |Postal address | | |
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| |Contact details: |Home | |Fax | | |
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| | |Work | |Cell | | |
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| | |Email | | |
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| |What is the highest academic, professional or trade qualifications? | |
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| |Have you or the Policyholder/Life Assured ever been insolvent or are any sequestration hearings proceeding, pending or |Yes No | |
| |contemplated? | | |
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| |Are you a smoker? |Yes No | |
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| |Have you ever been advised to stop smoking? |Yes No | |
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| |Do you consume alcohol? |Yes No | |
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| |Have you ever been advised to stop consuming alcohol? |Yes No | |
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| |Have you ever taken recreational drugs? |Yes No | |
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| |Name | | |Policy number | | |
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|2. |INFORMATION RELATING TO YOUR MEDICAL CONDITION |
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| |a) |Medical reasons for claim | | |
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| |b) |Medical condition is due to disease/accident: | |
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| | | Date diagnosed/date of event: | | |
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| |c) |If the medical condition resulted from an Accident please provide full details? |
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| |d) |If reported to the police, please provide the police station at which the accident was reported. | |
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| |e) |Case number | | |
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| |f) |If reported, we require a copy of the police report. | | |
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| |g) |Name, address and phone number of your doctors during the last 5 years: | |
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| |h) |Name, address of all attending doctor/s Hospital/s, Clinic/s including consultations for current condition: | |
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| |Doctor’s Name |Telephone Number |Reason for Consultation |Date of Consultation | |
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| |i) |What form of treatment are you currently undergoing/medication being taken, please list | | |
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|3. |Living Lifestyle, Femability, Careability, Impairment, Enability Benefits | |
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| |Please indicate what category you are claiming under: | | |
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|4. |DISABILITY DETAILS: Sections 4 and 5 to be used only when claiming for disability | |
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| |Absolute Protector, Lump Sum Disability benefits, Monthly Income Protection, Waiver Benefits, | |
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|5. |Particulars of PRESENT occupation: (Also applicable to self employed) | |
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| | a) |Name and address of last or present employer: | | |
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| | b) |Length of service with employer: | | |
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| | c) |What was your full-time occupation immediately before your current disability/impairment began? | | |
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| |d) |Breakdown of your duties: | | |
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| |ADMINISTRATIVE % |SUPERVISORY % |MANUAL % |TRAVEL % | |
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| | 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 | | |
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| |f) |How long have you been following this occupation? | | |
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| |g) |What date did you stop working? | | |
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| |h) |When do you expect to return to work? | | |
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| |i) |State particulars of your current avocations: | | |
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| |j) |Have you been offered or enquired about any alternative occupation for remuneration by your employer? |Yes No | |
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| |i) |If “Yes” describe duties of alternative occupation offered: | | |
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| |ii) |Have you accepted the alternate occupation offered? |Yes No | |
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| |iii) |If “Yes” when do you expect to follow the alternative occupation? | | |
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| | |On a full time basis: | |On a part time basis: | | |
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| | k) |Occupations held in the past 10 years: | |
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| |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 | | |
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|6. |INFORMATION RELATING TO YOUR INCOME (Liberty reserves the right to call for Financial evidence in order to assess the claim) | |
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| | a) |What was your taxable income for the past 12 months? | | |
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| | b) |Commission earned during the past 24 months: | | |
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| |c) |Directors fees for the past 24 months? | | |
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| |d) |Have you received any income or any other benefits since disablement? If “Yes”, please state income amount for every |Yes No | |
| | |month since disablement, including amounts, dates and source of income? | | |
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| | e) |Have you claimed or do you intend claiming for payment of disability, dread disease, impairment, or any similar |Yes No | |
| | |benefits with any other assurance companies? | | |
| | |If “Yes” please give details below: | | |
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| |NAME OF ASSURANCE CO. |POLICY NUMBER |DATE OF INCEPTION |ESTIMATED VALUE | |
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| |Name: | | Policy number: | | |
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|6. |PAYMENT DETAILS | |
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| |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. | |
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| |NAME OF ACCOUNT HOLDER | | |
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| |NAME OF BANK | |NAME OF BRANK | | |
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| |BRANCH CODE | |ACCOUNT TYPE | | |
| |(excluding credit card) |
| |ACCOUNT NUMBER | | |
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| |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. |
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|7. |DECLARATION | |
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| |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. | |
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| |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. | |
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| |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. | |
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| |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. | |
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| |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. | |
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| |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. | |
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| |Signed at | |this | |day of | |20 | | |
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| |Policyholders signature | | |
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| |Life assured’s signature | | |
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|MEDICAL CERTIFICATE FOR DISABILITY FROM ATTENDING DOCTOR |
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|To: Dr | |Patient/Claimant details | |
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|Address | |Name | | |
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| | |Policy number | | |
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| | |Date of birth/ID. no. | | |
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| | |Medical aid details: |Fund name | | |
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| | |Number | | |
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| | |Main member | | |
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|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. |
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|Note: Please ensure that this report is submitted to the Claims Department only and not to any other party |
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|Dear Doctor |
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|We would appreciate your co-operation in providing the information requested in this form. |
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|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. |
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|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. |
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|I authorise you to disclose to Liberty any information you may have concerning my health and habits. |
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|The fee payable for this report is in accordance with Liberty’s medical tariffs. |
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|Please do not hesitate to contact us if you require any further information. |
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|Thanking you in anticipation. |
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|Yours faithfully |
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|Liberty |
|Claims Management |
|Name | |Policy number | | |
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|CLAIMANT’S DETAILS |
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| |Full name of claimant | | |
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| |Date of birth | | | |
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| |ID number (if known) | | |
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| |Occupation (including description of duties) | | |
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| |Hiighest qualification | |Last day at work | | |
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|MEDICAL HISTORY |
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| |1. |Reason for claim | | |
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| |2. |Date diagnosed | | |
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| |3. |Date symptoms started: | | |
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| |4. |Date first seen by you for this reason | | |
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| |5. |Date stopped work | | |
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| |6. |Date expected to return to work | | |
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| |7. |Name of referring doctor | | |
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| |8. |Doctor’s contact number | | |
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| |9. |Have you seen him/her for any other conditions? (please give dates and details below) | |
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| | Date |Reason for Consultation |Treatment Prescribed |Duration of Complaint | |
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| |MEDICAL REFERENCES | |
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| |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 | | |
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|MEDICAL HISTORY (CONTINUED) | |
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|Please give full medical history, including the following: | |
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| |Symptoms and diagnosis | | |
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| |Dates of any diagnoses of any other conditions | | |
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| |Clinical details indicating severity and permanence | | |
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| |Relevant test results (eg. lung function readings, X-ray or scan results) etc. | | |
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| |Treatment and response/ Compliance to treatment/How often does he/she require treatment | | |
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| |Other comments | | |
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| Current major complaint(s) | | |
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|RESULTS OF MOST RECENT MEDICAL EXAMINATION (We do not require actual examination) | |
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|Date of last examination | | |
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|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). | |
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|Does the claimant use tobacco in any form? |Yes No | |
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|If “Yes” please provide details: | | |
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|Is current medical impairment due to: | |
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| |a) |Previous illness or injury: |Yes No | |
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| |b) |The intentional consumption of alcohol, narcotics or any toxic substance: |Yes No | |
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| |c) |Attempted suicide or any self inflicted injury: |Yes No | |
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| |d) |Taking of drugs other than under the directions of a registered medical practitioner: |Yes No | |
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|PROGNOSIS | |
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|What are chances of recovery (good/fair/poor/nil)? | | |
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|Are any residual problems likely? Please specify: | |
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|If period off work longer than usually expected for recovery for this condition, please give reasons: | | |
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|Date expected to return to work: | | |
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|Is this form completed after an examination or from records? | | |
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|Date of records? | | |
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|Is he/she able to handle their own financial affairs? | Yes No | |
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|Name | |Policy number | | |
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|In all instances this form must be completed |
|FUNCTIONAL ABILITIES | |
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|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 |Moderate |Impossible |Improve |Remain |Deteriorate | |
| | | |Limitation |Limitation | | |constant | | |
| |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 | | | | | | | | |
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|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: | | |
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|TREATMENT AND REHABILITATION | |
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|Current medication regime. Please specify all medications and dosages: | |
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|Other treatment the claimant has received or is currently receiving (e.g. physiotherapy, occupational therapy, psychotherapy): | |
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|Planned future treatment, including surgery: | |
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|Your recommendations regarding rehabilitation (if applicable): | |
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| |Please attach copies of any correspondence received from any practitioners, specialists or hospitals in respect of the claimant. | |
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|Doctor’s details |
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|Name of doctor | |Practice number | | |
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|Postal address | | |
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|Telephone number | |Facsimile number | | |
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|Email address | |Qualifications | | |
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|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. |
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|Signature of doctor | |Date of report | | |
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|Please supply the following details in order for us to pay your account: |
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|Name of bank | | |
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|Account number | |Branch code | | |
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|EMPLOYER’S DECLARATION |
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|Please print in block letters and use black pen |
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|IF SELF EMPLOYED, TO BE COMPLETED BY AUDITOR/BOOKKEEPER OR RELEVANT THIRD PARTY |
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|A. |PERSONAL PARTICULARS OF EMPLOYEE | |
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|Policy number/s | | |
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|Full name of employee | | |
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|Identity number | |Date of birth | | |
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|Medical aid scheme | | | |
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|Membership number | |Employees tax number | | |
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|B. |PARTICULARS OF OCCUPATION | |
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|1. |What was his/her full time occupation immediately before his/her disability? | | |
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|2. |Commencement date of occupation | | |
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|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. | |
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|4. |Percentage of time spent engaged in: | |
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| |ADMINISTRATIVE DUTIES% |SUPERVISORY DUTIES % |MANUAL DUTIES % |TRAVELLING DUTIES % | |
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|5. |(a) |When was he/she last actively able to perform part of the duties of his/her full time occupation? | | |
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| |(b) |Has he/she been medically boarded or was his/her services terminated? | | |
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| |(c) |Official boarding date/date services terminated | | |
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| |(d) |Reasons for termination | | |
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| |(e) |Is he/she still being paid? If No, when was the last time? | | |
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| |(f) |Until what date is renumeration expected to be paid? | | |
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| |(g) |Anticipated date that the employee will return to work: | | |
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| |(h) |Is he/shestill engaged in any part of his/her occupation? |Yes No | |
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|6. |Are you aware if he/she is engaged in any occupation(permanent or part time) after his/her disablement? |Yes No | |
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| |If “Yes”, please provide details, including dates below | |
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| |Occupation |Dates | |
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| |Name | |Policy number | | |
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|C. |INFORMATION REQUIRED WITH REGARDS TO ALTERNATIVE DUTIES | |
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|1. |Has any consideration been given to the extent to which the employee’s work circumstances or duties might be adapted to |Yes No |
| |accommodate the employee’s disability needs? If ‘No”, furnish reasons: | |
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|2. |If “YES”, in what capacity? | | |
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|3. |In the event of being self employed, please state if business is to continue. |Yes No |
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| |If “Yes”, please specify the amount still being paid to the life assured: |R | |
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|D. |DETAILS OF FUNCTIONAL INCIDENT/ILLNESS | |
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|1. |What was the cause of him/her not being able to work? | | |
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|2. |If he/she was injured on duty, please provide us with a short description of the circumstances of the incident/accident: | |
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|3. |Please supply brief history of sick leave, for 2 years prior to disability, for any absence exeeding 2 days: | |
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| | Date |Details of illness or injury |Number of working days absent |Doctors consulted | |
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|E. |INFORMATION ON INCOME | |
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|1. |What are the details of remuneration for past 12 months? |R | |
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| |Has he/she suffered any loss of income since the illness/injury? |Yes No |
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|2. |If “Yes”, was income stopped or reduced? If reduced – to how much? |R | |
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|3. |Amount still being paid: |R | |
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|F. |SOURCE OF INCOME | |
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|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 |
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|2. |If “Yes”, please give full details | | |
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| |Name | |Policy number | | |
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|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.) |
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|Name | |Position/Relationship | | |
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|Company | |Telephone number. | | |
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|Physical address (or company stamp) | | |
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|Signature | |Date: | / / | |
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|Employee’s email / website address | | |
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|MEMBER INFORMATION FORM (SARS REQUIREMENTS) |
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|“*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 |
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|Surname/Entity name | |Policy number | | |
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|First two names | | |
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|Initials | |Date of birth | / / | |
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|RSA identity number | |Income tax number. | | |
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|Passport no.(if foreigner) | |Passport or other identity | | |
|or other identity number | |country of issue | | |
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|Contact email | | |
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|Home telephone number | |Fax number | | |
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|Business telephone no. | |Cell number | | |
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|MEMBER PHYSICAL ADDRESS DETAILS - RESIDENTIAL |
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|Complete your residential address | | |
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| |Postal code | | |
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|MEMBER ADDRESS DETAILS – POSTAL |
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|Mark here with an “X” if same address as above | | | | |
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|or complete your postal address | | |
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|Postal code | | |
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|MEMBER PHYSICAL ADDRESS DETAILS – BUSINESS / EMPLOYER |
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|Complete your physical business / | | |
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|employer address | | |
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| |Postal code | | |
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|Member signature | |Date | / / | |
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|Please fax your forms to (011) 408 2005 alternatively, please email your form to opsclaims@liberty.co.za | |
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