JUA Underwriting Agency Pty Limited

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JUA Claim Notification Form for Personal Accident Insurance.
JUA prides itself on responsiveness and prompt settlements. Please submit this Form and a JUA consultant will respond to you within 2 working days.


	1. Insurance Broker

	Name of the Insurance Broking Firm:
	Address:

		Suburb: State: Postcode:
	Name of the Insurance Broker:
	Contact details:	Phone :
		Fax:
		Email:


	2. The insured

	Policy Number:
	Insureds name:
	Claimants name:
	Address:

		Suburb: State: Postcode:
	Tax Status:	Registered Business: Yes No
		ABN:
		Taxable %:
	Contact numbers:	Private:
		Business:
		Mobile:
	Date of Birth:
	Physical size:	Height: cm Weight: kgs
	Sex:	Male Female
	Occupation:	Describe your usual duties:


	3. Claim details

Give a full description below of injury or illness for which you are claiming.
Illness:	Condition:
	When did it commence?

Injury:	How were you injured?

	What injuries did you receive?

	What were you doing when you were injured?

	Where did the accident occur?

	Details of person who witnessed the accident.
	Surname: Given Name(s):
Address:

	Suburb: State: Postcode:
Contact Numbers:	Business:
	Private:
	Mobile:
	Did the injury occur during the course of your usual occupation? Yes No
	If the injury resulted from a motor vehicle accident were you required to undergo a breath analysis or blood test?
	No Yes(attach a copy of analysis result.)
Have you ever had this, or similar condition, in the past? No Yes give details
	Condition:
	Treated By:
	Date:
Give the exact date when illness began, or injury occurred.
	Date:	Time:
When did you first consult a doctor for this condition?
	Date:	Time:
When did you become totally disabled (unable to work)?
	Date:	Time:
If still disabled, when do you expect to return to work?
	Date:	Time:
If you have returned to work, when were you able to again perform:
	a) One or more of the material tasks of your occupation?
	Date:
	b) All the tasks of your occupation?
	Date:
If you were admitted to a hospital, or treated as an outpatient, please give details below.
Name of Hospital Address FromToIn/OutPatient
Details of all attending physicians
Name Address Tel. Number
Who is you usual family doctor?
Name Address Tel. Number
How long have you been receiving treatment or advice from this doctor? years months
What other medical or surgical treatment has been received during the past 5 years?
DateNature of Treatment Doctor's NameAddress
Are you now, or have you ever been, subject to or affected by any other injury, disease, deformity, defect of senses, infirmity or weakness?
No Yes - If Yes, give details:

Have you ever lodged a personal accident or illness claim before?
No Yes - If Yes, give details:

Are you making or entitled to make any other insurance or compensation claim in respect of this disability?
Sick Leave Yes No Motor Compensation Yes No
Workers' Compensation Yes No Private Health Fund Yes No
Superannuation Life Insurance Yes NoOther Government Benefits Yes No
Name of Fund(s)/Insurance Company:
Name of previous employers over last 5 yearsFrom To

Important: Please attach an attending physician's statement, to be completed by your doctor. Your Claim cannot be processed until we receive your completed claim together with the attending physicians statement. We will also require Medical Certificates each month from the date of disablement and a final certificate showing the actual date you resumed work.


	4. Declaration of Earnings

	Important Information:
	1.	If you are self-employed, Weekly Earnings means Your weekly earnings derived from personal exertion after allowing for the costs and expenses in incurring that income. Please complete Section A.
	2.	If you are not self-employed, Weekly Earnings means your weekly remuneration earned from personal exertion by way of salary, fees, wages, commissions and any other items already agreed by us. Please complete Section B.
	3.	You may be required to supply proof of your income by submitting copies of your personal and / or business income tax returns for the full financial year immediately preceding the injury or illness for which you are now claiming.


	A - Self-employed Persons (To be completed by your accountant)

	Business/Trading Name:
	Address:

		Suburb: State: Postcode:
	Was the business fully operational and was the Insured fully employed at the time of suffering the accident or contracting the illness?
		No Yes. Give details:

	Does the business have Workers Compensation Insurance?
		No Yes. Give details:

	Please state the current weekly earnings (See Important Information 1 above.):

	Accountant's Name:
	Accountant's Signature:


	B - Employed Persons: (To be completed by your employer)

Business/Trading Name:
Address:

	Suburb: State: Postcode:
Please state the current weekly earnings (See Important Information 2 above.)
	$
Is the Insured Person entitled to Workers' Compensation benefits?
	No Yes give details of payments.
	a) Weekly Rate	$
	b) Monies Paid to Date	$
Was the Insured Person in your employ at the time of suffering the injury or illness?
	Yes No
Is the Insured Person entitled to receive sick leave?
	Yes No
	Number of days entitled:	days
Has the Insured Person received any sick leave payments in respect of the injury or illness for which he/she is claiming?
	Yes No
	Number of days entitled:	days
Please advise the Insured Persons gross salary at the date of injury of illness.
	$
Officers Name:
Position:
Telephone Number:
Signature:
Date:


	Privacy

	Amendments to the Privacy Act 1988 took effect on 21 December 2001. You can review our Privacy Policy on this website, accessible from the top right hand navigation menu. Please contact JUA for any further information.


	Declaration and Authorisation

	The information and answers given above are true and complete in every detail. I understand the claim may be refused, delayed or reduced if information is withheld. I authorise that JUA Underwriting Agency Pty Limited give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the Insured's credit or insurance history as well as insurance claims information obtained during the course of this contract.
	Name
	Date

			Print your Claim Notification details, sign it and fax to: (02) 9247 2411. Remember to also fax any necessary attachments.