Combined Insurance Claim Template

Combined Insurance Claim Template

The Combined Insurance Claim Form is a document used to submit a claim for benefits provided under your insurance policy with Combined Insurance, a division of Chubb Insurance New Zealand Limited. Completing this form accurately and thoroughly is essential for a smooth claims process. To begin, please fill out the form by clicking the button below.

Table of Contents

The Combined Insurance Claim Form is a crucial document for individuals seeking benefits under their insurance policy with Combined Insurance, a division of Chubb Insurance New Zealand Limited. Completing this form accurately and promptly can significantly impact the speed at which claims are processed. The form consists of several sections that require detailed information about the claimant, including personal details, medical history, and specifics regarding the incident or condition leading to the claim. Claimants must provide supporting documents, such as medical reports or hospital statements, to substantiate their claims. The form also includes sections for medical practitioners to fill out, ensuring that all necessary medical information is captured for assessment. Timeliness is essential; claims should be submitted within 30 days of the incident to avoid delays. Additionally, the claims process includes steps for acknowledgment, assessment, and potential follow-up requests for further information. Understanding these aspects is vital for a smooth claims experience.

Combined Insurance Claim Sample

Page 1 of 7
Claim Form
Combined Insurance
Important Notes for Particular Benefits
11. If your Policy covers you for benefits while you
are hospitalised, please attach a copy of your hospital
statement showing the dates of admission and discharge.
If you were in intensive care during your period of
hospitalisation, the Statement should indicate this.
12. If you are claiming for a Fracture Benefit, please attach
a copy of the medical report verifying a fracture.
13. If you are claiming for Covered Cancer please attach
a copy of a Pathology, Histology, or Histopathology
Report, that medically verifies the diagnosis and a copy
of your hospital statement showing any out-patient
treatments if you are claiming an Out-patient
Treatment benefit.
14. If you are claiming a benefit for Skin Cancer,
please attach a medical statement verifying this.
15. If you are claiming a Transportation benefit
please attach a receipt for your travel expenses.
16. If you are claiming a Family Lodging benefit
please attach a copy of your hotel/motel bill.
17. If you are claiming a Facial Disfigurement benefit, please
send a photograph of the relevant scar with your claim
form. Please note that we may require you to submit a
further photograph of your scar if your injury had not
fully healed at the time you first lodged your claim.
18. If you are claiming an Emergency Ambulance benefit,
please attach a copy of your ambulance statement
or account.
Important Instructions
Important Instructions on how to complete the attached Claim Form and how we assess claims. Please read these
important instructions on how to complete the attached Claim Form. This may help us to assess your claim faster.
In this ‘Important Instructions’ section we refer to the Insured
or Covered Person as “you” or “your”; and Combined Insurance
a division of Chubb Insurance New Zealand Limited (Chubb)
as “Combined Insurance”, “we”, “our” or “us”, in the following
instructions.
We refer to Chubb Insurance New Zealand Limited (Company No.
104656 Financial Services Provider No 35924) as “Chubb”.
1. It is important that you contact us as soon as possible once
you are aware of any circumstance or event giving rise to a
claim and provide honest, complete, up-to-date and relevant
information when completing this claim form.
2. You should complete Section 1 in full to the extent relevant
and attach any relevant invoices and other documents to
support your claim. If you do not fully complete the Claim
Form this may result in delays processing your claim while we
seek missing information. Please see the Important Notes for
Particular Benefits.
3. Your Medical Practitioner, and only your Medical Practitioner
should complete Section 2 in full to the extent relevant. Your
Medical Practitioner must
also sign and date the Claim Form in
the appropriate place.
4. We normally pay benefits up to the date that your Medical
Practitioner has signed the Claim Form. If your disability is
ongoing after that date, we will send you a Continuing Claim
Form or Progress Form which your Medical Practitioner
should sign and complete on your next visit.
Once we have received this completed form, we can make
a further payment up to the date your Medical Practitioner
has signed the form. The reason we do not pay benefits in
advance of when your Medical Practitioner signs a Claim Form,
is that the future disability has not yet occurred, and insurance
only pays for losses that have already occurred. We follow
this procedure even if your Medical Practitioner states an
‘approximate date’ for your disability to end. Of course, all
payments depend on your claim falling within the terms
and conditions of your Policy.
5. We may ask you or your Medical Practitioner for more
information concerning your claim, or we may arrange
a further independent assessment by a Specialist of
our choosing.
6. Please send this Claim Form together with all supporting
documents within 30 days of the commencement of your
disability via post to Combined Insurance, Private Bag
COMBINED, Remuera, Auckland 1541, via fax to 09-520-9009,
or email the form to claims@combined.com. If you do not
report your claim within 30 days and we consider the delay has
prejudiced our ability to assess your claim, this may affect and/
or delay payment of your claim.
7. Our Claims Process
On receipt of this completed claim form we will take the
following steps:
• Acknowledge receipt of your claim within 5 business days.
• Identify your insurance policy, register your matter against
it and assign a claim number for reference. Determine
whether or not to accept your claim within 10 business
days of the date we have all the information we need to
determine your claim.
• If we are unable to determine whether or not to accept
your claim within 10 business days, such as when we
request that you provide further information from your
doctor or employer, we will advise you of the additional
information we require. You must cooperate with us by
providing the information we seek to settle your claim.
• If we require information from an independent specialist, or
a doctor or other third party which we request directly, then
we will advise you of the information required and will provide
you with an estimate of how long we expect it will take to
determine your claim, once we have this information.
•
We will update you once every 20 business days, or
another such interval as we may agree with you, until your
claim is resolved.
8. With the exception of some circumstances, you have a right
to access the information we have relied on in evaluating
your claim and you can ask us to correct any mistakes or
inaccuracies in that information.
9.
If we decline your claim in whole or in part, we will clearly explain
the reason or reasons. You have a right to access our Complaints
and Disputes Resolution process which is summarised on the
back page of this claim form.
10. Should you require any assistance in completing this Claim
Form, or have any queries about claiming, or how we assess
a claim, please contact us on 0800 COMBINED (266 246)
and we will be happy to assist you.
A division of Chubb Insurance New Zealand Limited
Page 2 of 7
Fair Insurance Code
Chubb is a member of the Insurance Council of
New Zealand (ICNZ) and a signatory to ICNZ’s
Fair Insurance Code (the Code). The Code and
information about the Code is available at
http://www.icnz.org.nz/ and on request.
Privacy Statement
Combined Insurance is a division of Chubb Insurance New Zealand
Limited. Chubb collects, uses and retains your personal information
in accordance with Chubb’s Privacy Policy, which also applies to
Combined Insurance.
This statement is a summary of Our privacy policy and provides
an overview of how We collect, disclose and handle Your personal
information. Our privacy policy may change from time to time and
where this occurs, the updated privacy policy will be posted on Our
website.
Chubb is committed to protecting Your privacy. Chubb collects,
uses and retains Your personal information in accordance with
the requirements of New Zealand’s Privacy Act, as amended or
replaced from time to time.
Personal Information Handling Practices
When do We collect Your personal information?
Chubb collects Your personal information (which may include
health information) from You when You interact with Us, including
when You are applying for, changing or renewing an insurance
policy with Us or when We are processing a claim, complaint or
dispute. Chubb may also (and You authorise Chubb to) collect Your
personal information from other parties such as brokers or service
providers, as detailed in Our privacy policy.
Purpose of Collection
We collect and hold the information to oer products and services
to You, including to assess applications for insurance, to provide
and administer insurance products and services, and to handle any
claim, complaint or dispute that may be made under a policy.
If You do not provide Us with this information, We may not be able
to provide You or Your organisation with insurance or to respond
to any claim, complaint or dispute, or oer other products and
services to You or Your organisation.
Sometimes, We may also use Your personal information for Our
marketing campaigns and research, to improve Our services or in
relation to new products, services or information that may be of
interest to You.
Recipients of the Information and Disclosure
We may disclose the information We collect to third parties,
including:
• contractors and contracted service providers engaged by Us to
deliver Our services or carry out certain business activities on
Our behalf (such as actuaries, loss adjusters, claims investigators,
claims handlers, professional advisers including lawyers, doctors
and other medical service providers, credit reference bureaus
and call centres);
• intermediaries and service providers engaged by You (such as
current or previous brokers, travel agencies and airlines);
• other companies in the Chubb group;
• the policyholder (where the insured person is not the
policyholder);
• insurance and reinsurance intermediaries, other insurers, Our
reinsurers, marketing agencies; and
• government agencies or organisations (where We are required to
by law or otherwise).
These third parties may be located outside New Zealand. In
such circumstances We also take steps to ensure Your personal
information remains adequately protected.
From time to time, We may use Your personal information to send
You oers or information regarding Our products that may be of
interest to You. If You do not wish to receive such information,
please contact Our Privacy Ocer using the contact details
provided below.
Rights of Access to, and Correction of, Information
If You would like to access a copy of Your personal information, or
to correct or update Your personal information, want to withdraw
Your consent to receiving oers of products or services from Us or
persons We have an association with, please contact the Privacy
Ocer by posting correspondence to Chubb Insurance New
Zealand Limited, PO Box 734, Auckland; telephoning:
+64 (9) 3771459; or emailing Privacy.NZ@chubb.com.
How to Make a Complaint
If You have a complaint or would like more information about how
We manage Your Personal Information, please review Our Privacy
Policy for more details, or contact Our Privacy Ocer at the details
above.
You also have a right to address Your complaint directly to the
Privacy Commissioner by telephoning 0800 803 909, emailing
enquiries@privacy.org.nz or using the online form available on the
Privacy Commissioner’s website at www.privacy.org.nz.
Complaints and Dispute Resolution
We take the concerns of its customers very seriously and has
detailed complaint handling and dispute resolution procedures that
you may access, at no cost to you. To assist us with your enquiries,
please provide us with your claim or policy number (if applicable)
and as much information as you can about the reason for your
complaint or dispute.
Our complaints and dispute procedures are as follows:
Stage 1 – Complaint Handling Procedure
If you are dissatisfied with any of our products or services and you
wish to lodge a complaint, please contact us via:
Email: Complaints.NZ@chubb.com
Phone: COMBINED (266 246)
(call free within NZ)
+ 64 9 520 9000 (if calling from overseas)
Fax: +64 9 520 9009
Post: The Complaints Ocer
Combined Insurance
Private Bag COMBINED
Remuera Auckland 1541
Stage 2 –Dispute Resolution Procedure
If you are dissatisfied with our response to your complaint, you
can advise that you wish to take your complaint to Stage 2 and
referred to our dispute resolution team. Our internal dispute
resolution team can be contacted via:
Email: DisputeResolution.NZ@chubb.com
Phone: +64 9 377 1459
Fax +64 9 303 1909
Post: Internal Dispute Resolution Service
Chubb Insurance New Zealand Limited
PO Box 734
Shortland Street
Auckland 1140
Stage 3 – External Dispute Resolution
We are a member of an independent external dispute resolution
scheme operated by Financial Services Complaints Limited (FSCL)
and approved by the Ministry of Commerce & Consumer Aairs.
Subject to FSCL’s Terms of Reference, if you are dissatisfied
with our dispute determination or we are unable to resolve your
complaint or dispute to your satisfaction within two months you
may contact FSCL via:
Post: PO Box 5967, Lambton Quay, Wellington 6145
Phone: 0800 347 257 (call free for consumers) or
+64 4 472 FSCL (472 3725)
Fax: +64 4 472 3728
Email: info@fscl.org.nz
Website: www.fscl.org.nz
Please note if you would like to refer your complaint or dispute to
FSCL you must do so within 2 months of the date of our dispute
determination.
Further details regarding our complaint handling and dispute
resolution procedures are available from our website and on
request.
Page 3 of 7
Claimant’s Details
Office Use Only
IMPORTANT. Write your Account Number here
Claimant's Full Name:
Date of Birth: / / Height: Weight:
Residential Address: Postcode:
Postal Address
(If dierent from above)
: Postcode:
Claimant’s Telephone Number: Daytime: ( )
Mobile: ( )
Claimant’s Email Address : Occupation:
Employer’s Name: Employer’s Address:
Employer’s Contact Person:
Employer’s Contact Telephone Number: ( )
Are you claiming under a Family Policy? If Yes, please provide Family Policy Account Number:
No
Yes
Complete for Accident only
1. When did the accident occur? Date: / / at am / pm
2. Where did the accident occur? Street Number: Street Name:
Suburb: City/Town:
3. Nature of Injuries: (Please be specific)
4. How did the accident occur?
(Please be specific)
5. If it was a motor vehicle accident, please provide a description of the vehicle(s) involved.
(Note: if more than 2 vehicles involved attached details of other vehicles separately)
Your vehicle Registration No.: Make: Model:
The other person’s vehicle Registration No.: Make: Model:
6. Was the accident reported to the Police?
Date: / / Police Station:
Was anyone charged by the Police?
If Yes, who was charged?
What was the charge?
(Note: You must provide us with a copy of the Police Report if we request you to)
7. During the 24 hours before the accident, did you drink any alcohol or take any drugs?
(If Yes, please provide details - state types and quantities)
Did you have a Blood Alcohol Test or Drug Test by the Police?
If Yes, what was the result?
8. Were you transported to Hospital by Ambulance after the accident?
Name of Hospital you attended:
(Note: You must provide us with a copy of the Ambulance Report if we request you to)
9. Eye witness details. Please provide details of any eye witness.
Witness 1 - Full Name: Address:
Email Address: Telephone Number: ( )
Daytime
Witness 2 - Full Name: Address:
Email Address: Telephone Number: ( )
Daytime
Witness 3 - Full Name: Address:
Email Address: Telephone Number: ( )
Daytime
NoYes
NoYes
NoYes
NoYes
NoYes
SECTION 1
Claimant to complete this page
(Please print using BLOCK LETTERS)
Mr Mrs Ms Miss Other:
It is our preference to make claims payments by Electronic Funds Transfer (EFT).
Do you want us
to make payments on
this claim by EFT into
your account?
NoYes
A
If Yes to ‘A’, is the account
that you pay your premium from
the Account you want us to pay
your claim payments to?
NoYes
B
Account Name:
If No to ‘A’ and/or ‘B’, please provide
name of preferred Financial Institution:
Bank Branch Number Account Number Suffix
C
16. Which Medical Practitioner is currently treating you for your injury/illness? (If the same as ‘Q12’ write ‘As above’)
Medical Practitioner’s Name:
Medical Practitioner’s Address:
Medical Practitioner’s Telephone Number: ( )
When did you first see the Medical Practitioner for this condition? Date: / /
Other Dates of Treatment? (If Yes, please provide details)
17. Who is your usual family Medical Practitioner? (If the same as ‘Q16’ write ‘As above’)
Medical Practitioner’s Name:
Medical Practitioner’s Address:
Medical Practitioner’s Telephone Number: ( )
18. What other significant medical or surgical treatments have you received in the past 5 years? (Please provide details)
Date(s):
Nature of the condition(s) treated:
Name of treating Medical Practitioner/Specialist:
Address of Medical Practitioner/Specialist who treated you:
19. Are you aected by any other long term or chronic disability? (If Yes, please provide details)
20. Were you hospitalised? (If Yes, please state date of hospitalisation) From: / / To: / /
(Please also attach a copy of any hospital statements if you are hospitalised and claiming a confinement benefit)
21. Are you claiming for Transportation and Family Lodging Benefits?
(Please attach receipts supporting your claim if you are claiming for these)
22. If you are claiming a benefit as the result of the diagnosis of any covered Skin Cancer, please attach proof of diagnosis.
23. ‘Total Disability’. Between what dates were you unable to perform any duties?
(Refer to the ‘Definitions’ at the top of ‘Section 2’)
From: / / To: / /
24. ‘Partial Disability’. Between what dates were you able to perform only partial duties?
(Refer to the ‘Definitions’ at the top of ‘Section 2’)
From: / / To: / /
25. Date you returned to your normal duties. Date: / /
Page 4 of 7
Complete for Sickness only
10. Nature of sickness:
(Please be specific)
11. When were the symptoms first noticed? Date: / /
12. Who was the first Medical Practitioner you consulted for this condition?
Medical Practitioner’s Name:
Medical Practitioner’s Address:
Medical Practitioner’s Telephone Number: ( )
When did you first see the Medical Practitioner for this condition? Date: / /
13. Have you consulted any other Medical Practitioner for this condition?
(If Yes, please provide details)
Medical Practitioner’s Name:
Medical Practitioner’s Address:
Medical Practitioner’s Telephone Number: ( )
Dates of Consultations:
14. Did you go to Hospital in respect of this sickness?
(If Yes, please provide details)
Hospital Name:
Address:
Date of Admission: / / Date of Discharge: / / Number of Days in Hospital:
15. Have you previously had the same sickness?
(If Yes, please provide details)
Date(s):
Treatment Received:
Name of treating Medical Practitioner/Specialist:
Address of Medical Practitioner/Specialist who treated you:
No
Yes
NoYes
NoYes
Complete for Accident and Sickness
NoYes
NoYes
NoYes
NoYes
NoYes
Authority and Declaration
Chubb Insurance New Zealand Limited Claim Privacy Consent, Medical Authority and Declaration
Claim Privacy Consent
I/ we:
i. understand that Chubb Insurance New Zealand Limited
CU1-3, Shed 24, Princes Wharf, Auckland (Chubb)
requires personal information (which may include Health
information) so that Chubb can evaluate this claim and
administer the insurance policy and that failure to consent
to the collection, use and disclosure of personal information
may result in the claim being refused in part or in full;
ii. authorise Chubb to obtain from other parties personal
information (which may include Health information) about
me/us that Chubb views as relevant to the claim;
iii. agree to Chubb disclosing to other parties, including but
not limited to, service providers engaged by Chubb, the
insurance broker, the policy holder (if this differs from the
claimant) or reinsurers personal information (including
Health information) collected in relation to this claim or the
insurance policy;
iv. I authorise any person or entity, including but not limited
to Medical Practitioners and the Parties referred to in
the Privacy Consent, to provide to Chubb such personal
information (including health information) as Chubb in its
absolute discretion considers relevant for its assessment of
my claim or my entitlement to benefit;
v. understand that I/we have rights of access to, and
correction of, personal information held by Chubb; and
vi. understand that further information about how Chubb
collects, uses, discloses and processes my/our information
is set out in Chubb’s Privacy Policy, available at
www.chubb.com/nz-en/footer/privacy.html.
If you would like to access a copy of your personal information,
or to correct or update your personal information, please contact
Chubb’s Privacy Officer on +64 (9) 377 1459 or email
Privacy.NZ@chubb.com.
Authority and Declaration
I/ we:
• understand that in evaluating my/our claim or by accepting documents in support of my/our claim, Chubb has made no
acceptance of liability, nor waived any of its rights;
• confirm that any information that I/we supply will be true, correct and complete and that I/we will not withhold any information
likely to affect the acceptance or handling of my/our claim and understand that if I/we provide untrue information or do not
disclose relevant information that it might result in my/our claim being declined in part or in full;
• will give all reasonable assistance to Chubb and co-operate in the assessment of my/our claim; and
• appoint Chubb to do everything necessary to give effect to the consents and authorisations in this document and to execute,
on my/our behalf, any documents or to do such acts required to give effect to this Privacy Consent and Authority.
Name of
claimant:
Signature of
claimant:
X
Date:
/ /
Name of
Witness:
X
Signature of
Witness:
Date:
/ /
Page 5 of 7
Page 6 of 7
Medical Practitioner only to complete this section
This section must be fully completed by a Legally Qualified Medical Practitioner, at the Claimant’s expense.
Definitions
Total Disability
The inability to perform each of the substantial
duties of your business or occupation (usual
activities if not employed).
Partial Disability
The inability to perform one or more, but not
all of the substantial duties of your business or
occupation (usual activities if not employed).
Medical Practitioner
Means a licenced medical practitioner operating
within the scope of his or her New Zealand licence
and who is not a member of your immediate family.
Please read carefully before completing this section.
Patient’s Full Name:
/ /
Date of Birth:
1. Please tick whether claim is for:
Diagnosis:
Cause:
2. If the patient is suering from an injury, how did the patient advise you that the injury occurred?
3. Please Complete for Fractures only. Was the Fracture confirmed by an X-Ray?
(Please attach a copy of the X-Ray report)
Describe the type of Fracture:
4. When did the symptoms first appear, or the accident happen? Date: / /
5. When did the patient first consult you for this condition? Date: / /
Did Total Disability begin this day? If No, please state date total disability began Date: / /
6. Has the patient ever had this condition before?
If Yes, please state if the present condition is an aggravation or recurrence of a previous injury or sickness.
Recovery Date: / /
7. Has the patient ever had any other disease or infirmity that may be aecting the present condition?
If Yes, what was the disease or infirmity?
To what degree did this contribute to current disability?
8. Is the patient still under your care for this condition?
If Yes, and the patient has not recovered, what is the expected recovery date? / /
Please provide details of the Treatment Plan to assist the patient’s recovery:
If No, and the patient has recovered, please write the recovery date. Recovery Date: / /
9. Has the patient had surgery or is surgery anticipated? Date: / /
Details of surgery:
10. Has the patient been referred to any other Medical Practitioner or Specialist?
(If Yes, please provide details)
Medical Practitioner’s Name:
Medical Practitioner’s Address:
Medical Practitioner’s Telephone Number: ( ) Date Referred: / /
11. Are you the patient’s usual Treating Medical Practitioner? If Yes, for how many years?
If No, please advise the details of the patient’s usual Treating Medical Practitioner/Medical Practice.
Medical Practitioner/Medical Practice’s Name:
Medical Practitioner/Medical Practice’s Address:
Medical Practitioner/Medical Practice’s Telephone Number: ( )
SECTION 2
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
NoYes
InjurySickness
Medical Attendant Authority and Declaration
Chubb Insurance New Zealand Limited Privacy Consent and Declaration
Privacy Consent
I/ we:
i. understand that Chubb Insurance New Zealand Limited
CU1-3, Shed 24 Princes Wharf, Auckland requires
personal information (which may include my/our personal
information and the patient’s health information) so that
Chubb can evaluate the patient’s claim and administer their
insurance policy;
ii. agree to Chubb disclosing to other parties, including but
not limited to, service providers engaged by Chubb, the
insurance broker, the policy holder or reinsurers personal
information collected in relation to this claim or the
insurance policy;
iii. understand that I/we have rights of access to, and
correction of, personal information held by Chubb; and
iv. understand that further information about how Chubb
collects, uses, discloses and processes my/our information
is set out in Chubb’s Privacy Policy, available at
www.chubb.com/nz-en/footer/privacy.html.
If you would like to access a copy of your personal information,
or to correct or update your personal information, please contact
Chubb’s Privacy Officer on +64 (9) 377 1459 or email
Privacy.NZ@chubb.com.
Declaration
I/we confirm that to the extent I/we am/are aware, the information supplied in this form is true and correct.
Page 7 of 7
12. Disability Periods. (Refer to ‘Definitions’ at top of the opposite page)
a) Totally Disabled:
From: / / To: / / (Inclusive)
b) Partially Disabled
From: / / To: / / (Inclusive)
c) Hospitalised as an overnight In-patient
From: / / To: / / (Inclusive)
At: (Hospital Name)
d) Hospitalised as an overnight In-patient in Intensive Care
From: / / To: / / (Inclusive)
At: (Hospital Name)
e) Do you expect the patient to remain totally disabled for the next 12 months?
13. Is there any further medical information relevant to this claim?
No
Yes
WE RECOMMEND THAT A COPY OF THIS FORM IS TAKEN FOR YOUR FILES.
Medical Practitioner’s Declaration
MEDICAL PRACTITIONER’S
STAMP REQUIRED
Full Name of the
Medical Practitioner’s:
X
Signature of the
Medical Practitioner’s:
Date: / / Provider Number:
Qualifications:
Address: (If not on stamp)
Telephone Number: (If not on stamp) ( )
Email Address: (If not on stamp)
A division of Chubb Insurance New Zealand Limited
Combined Insurance is a division of Chubb Insurance New Zealand Limited
Chubb Insurance New Zealand Limited | Company No. 104656 | FSP No. 35924
Customer Service Phone 0800 COMBINED (266 246) Email claims@combined.com
Website www.combinedinsurance.co.nz
Postal Address Private Bag COMBINED Remuera Auckland 1541
Form Number: NZ00010 / ChubbNZ11-22-0721
▼ Combined Insurance Claim PDF Form

Document Attributes

Fact Name Description
Claim Submission Timeframe Claims must be submitted within 30 days of the event that triggered the claim.
Medical Practitioner Requirement Only your Medical Practitioner should complete Section 2 of the form, ensuring accurate medical information.
Supporting Documents Attach relevant invoices and documents to support your claim to avoid processing delays.
Claims Process Timeline The company acknowledges receipt of claims within 5 business days and aims to determine acceptance within 10 business days.
Access to Information You have the right to access and correct the information used in evaluating your claim.
Dispute Resolution If a claim is declined, the reasons will be clearly explained, and a dispute resolution process is available.
Privacy Compliance Chubb complies with New Zealand’s Privacy Act regarding the collection and handling of personal information.
Emergency Ambulance Benefit For claims related to ambulance services, a statement or account from the ambulance provider must be attached.
Fracture Benefit Documentation A medical report verifying a fracture must be submitted when claiming for a Fracture Benefit.
Hospitalization Benefits For claims related to hospitalization, a copy of the hospital statement showing admission and discharge dates is required.

Combined Insurance Claim: Usage Instruction

Completing the Combined Insurance Claim form requires careful attention to detail. Each section must be filled out accurately to ensure a smooth claims process. Following the steps outlined below will help in submitting a complete and timely claim.

  1. Gather all necessary documents, including any invoices, medical reports, and hospital statements relevant to your claim.
  2. Begin with Section 1. Fill in your personal details, including your full name, date of birth, height, weight, and addresses. Ensure that all information is accurate.
  3. Provide your contact information, including telephone numbers and email address, as well as your occupation and employer details.
  4. If applicable, indicate whether you are claiming under a Family Policy and provide the Family Policy Account Number.
  5. Decide if you prefer to receive claim payments via Electronic Funds Transfer (EFT) and provide the necessary banking details if applicable.
  6. For accident claims, complete the specific questions regarding the accident, including the date, location, nature of injuries, and any police involvement.
  7. For sickness claims, provide details about your condition, including when symptoms first appeared and the medical practitioners you consulted.
  8. Complete any additional questions regarding your medical history, treatments, and hospitalizations as required.
  9. Review your answers for completeness and accuracy. Ensure that all relevant documents are attached to support your claim.
  10. Sign and date the form, and have a witness sign as well if required.
  11. Submit the completed claim form and supporting documents within 30 days via post, fax, or email as specified in the instructions.

Frequently Asked Questions

  1. What should I do if I want to file a claim?

    If you wish to file a claim, it’s essential to contact Combined Insurance as soon as you become aware of any event that may give rise to a claim. Complete the Claim Form thoroughly, providing all relevant details and attaching any supporting documents, such as invoices or medical reports. This will help expedite the assessment of your claim.

  2. Who needs to fill out Section 2 of the Claim Form?

    Section 2 must be completed by your Medical Practitioner. They should provide all relevant information regarding your condition and sign and date the form in the designated area. This section is crucial for the assessment of your claim, as it provides the necessary medical evidence of your condition.

  3. What happens if I do not submit my claim within 30 days?

    It is important to submit your claim within 30 days of the start of your disability. If you fail to do so, and if the delay affects Combined Insurance's ability to assess your claim, it may result in a delay or even a denial of your claim. Timely submission is key to ensuring a smooth claims process.

  4. How will I know the status of my claim?

    Once your claim form is received, Combined Insurance will acknowledge receipt within 5 business days. They will then assess your claim and typically determine whether to accept or decline it within 10 business days, provided they have all necessary information. If they need additional information, they will inform you and keep you updated every 20 business days until your claim is resolved.

  5. What if my claim is declined?

    If your claim is declined, Combined Insurance will provide a clear explanation of the reasons for the decision. You have the right to access their Complaints and Disputes Resolution process if you disagree with the outcome. This process is designed to help you address your concerns and seek a resolution.

Common mistakes

When filling out the Combined Insurance Claim form, many people make common mistakes that can delay the processing of their claims. One frequent error is not providing complete and accurate information. The form requires detailed responses, and leaving sections blank or providing vague answers can lead to unnecessary delays as the insurance company seeks clarification.

Another mistake is failing to attach necessary supporting documents. Each claim type requires specific documentation, such as medical reports or hospital statements. Without these documents, the claim may be rejected or delayed. It is essential to review the instructions carefully and ensure all required attachments are included.

Some individuals overlook the importance of having their Medical Practitioner complete Section 2. This section must be filled out entirely by the Medical Practitioner, including their signature and date. If this step is missed, the claim cannot be processed, and the claimant will have to return to their doctor for completion.

Timing is also crucial. Submitting the claim form more than 30 days after the disability begins can lead to complications. If the insurance company believes the delay affects their ability to assess the claim, it may result in a denial or delayed payment. It is best to submit the claim as soon as possible.

People sometimes forget to provide their contact information accurately. This includes phone numbers and email addresses. If the insurance company cannot reach the claimant for additional information, it can slow down the entire process. Clear communication is vital for a smooth claims experience.

Additionally, some claimants do not keep copies of their submitted forms and documents. Having a personal record can be beneficial if there are questions or issues later on. It's a good practice to make copies before sending anything to the insurance company.

Another common mistake is misunderstanding the definitions of "total disability" and "partial disability." Claimants should carefully read the definitions provided in the form to ensure they accurately describe their condition and the dates they were affected. Misinterpretation can lead to incorrect claims and potential denial.

Lastly, not following up on the claim status can be a mistake. Once the claim is submitted, it is important to stay in touch with the insurance company. Regular updates can help identify any issues early and ensure the claim is processed promptly.

Documents used along the form

When filing a claim with Combined Insurance, several additional documents may be required to support your submission. Each of these documents serves a specific purpose in ensuring that your claim is processed efficiently and accurately. Here’s a brief overview of some commonly used forms and documents that often accompany the Combined Insurance Claim Form:

  • Medical Report: This document, typically completed by your treating physician, outlines your medical condition and the treatment provided. It helps verify the nature of your illness or injury and is crucial for substantiating your claim.
  • Hospital Statement: If you were hospitalized, this statement details your admission and discharge dates. It may also include information about any procedures performed during your stay, which is essential for claims related to hospitalization benefits.
  • Police Report: In cases of accidents, a police report may be necessary. This document provides an official account of the incident, including any charges filed, which can influence the outcome of your claim.
  • Receipts for Expenses: If you are claiming benefits for transportation or lodging, receipts for these expenses must be attached. They serve as proof of the costs incurred and are vital for reimbursement.

Providing these documents alongside your Combined Insurance Claim Form can significantly expedite the claims process. It’s essential to ensure that all information is accurate and complete to avoid delays. Always keep copies of your submissions for your records, and don’t hesitate to reach out to Combined Insurance for assistance if needed.

Similar forms

  • Health Insurance Claim Form: Similar to the Combined Insurance Claim form, this document requires details about medical treatments and conditions. Both forms ask for information from medical practitioners to support claims.
  • Accident Claim Form: Like the Combined form, this document focuses on claims arising from accidents. It requests specific details about the incident, including dates, witnesses, and medical treatment received.
  • Disability Claim Form: This form is comparable as it addresses claims for disabilities. Both require medical documentation and details about the claimant's condition and treatment history.
  • Life Insurance Claim Form: Similar in structure, this document seeks information about the deceased, including medical history and cause of death. Both forms necessitate supporting documents to process the claim.
  • Workers' Compensation Claim Form: This form is used for work-related injuries and parallels the Combined Insurance Claim form by requiring details about the incident and medical treatment.
  • Travel Insurance Claim Form: Both forms require information about incidents that led to a claim. The travel form asks for specifics about travel disruptions or medical emergencies while traveling.
  • Property Damage Claim Form: Similar to the Combined form, this document focuses on claims related to property loss or damage. It requires details about the incident and supporting documentation.
  • Critical Illness Claim Form: This form is akin to the Combined Insurance Claim form in that it requires detailed medical information and documentation to substantiate the claim for critical illnesses.
  • Long-Term Care Claim Form: Like the Combined form, this document requires information about ongoing medical care and treatment, along with documentation from healthcare providers.
  • Supplemental Insurance Claim Form: Similar in nature, this form addresses additional benefits beyond primary insurance. Both require detailed medical information and supporting documents to process claims.

Dos and Don'ts

When filling out the Combined Insurance Claim form, it’s important to ensure that you follow the correct procedures. Here’s a list of things you should and shouldn’t do:

  • Do contact Combined Insurance as soon as you become aware of an event that may lead to a claim.
  • Do provide honest, complete, and up-to-date information on the form.
  • Do fill out Section 1 thoroughly and attach any relevant documents to support your claim.
  • Do have your Medical Practitioner complete Section 2 and ensure they sign and date the form.
  • Do submit the claim form and supporting documents within 30 days of your disability starting.
  • Do keep copies of all documents you send for your records.
  • Do follow up with Combined Insurance if you haven’t received an acknowledgment within 5 business days.
  • Don’t leave any sections of the form blank if they are relevant to your claim.
  • Don’t delay in submitting your claim, as this may affect the processing time.
  • Don’t provide false or misleading information, as this can lead to your claim being denied.
  • Don’t submit the claim form without your Medical Practitioner’s signature in Section 2.
  • Don’t forget to include all necessary supporting documents specific to your claim type.
  • Don’t hesitate to reach out to Combined Insurance if you have questions about the process.
  • Don’t assume that your claim will be processed without following up if there are delays.

Misconceptions

  • Misconception 1: The Combined Insurance Claim Form is optional.

    • Some people believe that filling out the claim form is not mandatory. In reality, submitting this form is essential to initiate the claims process. Without it, your claim cannot be assessed.

  • Misconception 2: You can submit the claim form anytime.

    • Many assume there is no deadline for submitting the claim form. However, you must send it within 30 days of the start of your disability. Delays beyond this timeframe can affect your claim's approval.

  • Misconception 3: Any medical professional can complete the medical section.

    • Some individuals think any doctor can fill out Section 2 of the form. This is incorrect. Only your treating medical practitioner should complete this section and provide their signature.

  • Misconception 4: You will receive payment before the medical practitioner signs the form.

    • It is a common belief that payments can be made in advance of the medical practitioner’s signature. However, benefits are paid only up to the date the practitioner has signed the form, as insurance covers losses that have already occurred.

  • Misconception 5: You don’t need to provide supporting documents.

    • Some claimants think they can submit the form without any additional documentation. In fact, attaching relevant invoices and medical reports is crucial for a smooth claims process.

  • Misconception 6: Once you submit the claim, you won't hear back until it's resolved.

    • Many believe that after submitting their claim, they will not receive updates until a decision is made. In reality, you will receive acknowledgment within five business days and updates every 20 business days until your claim is resolved.

  • Misconception 7: You cannot access information used to evaluate your claim.

    • Some people think they have no right to see the information used in their claim assessment. This is not true. You can access this information and request corrections if there are any inaccuracies.

Key takeaways

Here are key takeaways for completing and using the Combined Insurance Claim form:

  1. Contact Promptly: Notify Combined Insurance as soon as you become aware of a claim-related event.
  2. Complete Section 1: Fill out Section 1 thoroughly and attach any supporting documents, such as invoices.
  3. Medical Practitioner’s Role: Only your Medical Practitioner should complete Section 2, including their signature and date.
  4. Ongoing Disability Claims: If your disability continues after the initial claim, a Continuing Claim Form will be required for further payments.
  5. Submit Timely: Send the claim form and all documents within 30 days of your disability to avoid delays.
  6. Claims Process: Expect acknowledgment of your claim within 5 business days and a decision within 10 business days if all information is provided.
  7. Access to Information: You have the right to access the information used to evaluate your claim and correct inaccuracies.
  8. Explanation for Declines: If your claim is denied, Combined Insurance will provide a clear explanation.
  9. Assistance Available: For help with the claim form or any questions, contact Combined Insurance at 0800 COMBINED (266 246).
  10. Documentation for Specific Claims: Attach required documents for specific benefits, such as hospital statements for hospitalization claims or medical reports for fractures.