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Blank Combined Insurance Claim PDF Form

The Combined Insurance Claim Form is a document used to report and process claims with Combined Insurance, a division of Chubb Insurance New Zealand Limited. Completing this form accurately and promptly is essential for a smooth claims process. To get started on your claim, please fill out the form by clicking the button below.

Article Guide

The Combined Insurance Claim Form serves as a crucial tool for individuals seeking to file claims with Combined Insurance, a division of Chubb Insurance New Zealand Limited. This form is designed to streamline the claims process by guiding claimants through the necessary steps to provide accurate and complete information. To ensure a smooth experience, it is imperative to contact Combined Insurance promptly upon discovering an event that may lead to a claim. The form is divided into sections, with Section 1 requiring the claimant to detail personal information, including contact details, occupation, and specifics about the incident leading to the claim. Section 2 must be completed by a medical practitioner, who will provide essential medical information and verify the claimant's condition. Supporting documents, such as medical reports and invoices, play a vital role in substantiating the claim. Timeliness is emphasized, as claims should be submitted within 30 days of the event to avoid delays. The form outlines the claims process, which includes acknowledgment of receipt, assessment timelines, and the potential need for additional information. Furthermore, it details the claimant's rights regarding access to their personal information and the procedure for addressing disputes. Overall, the Combined Insurance Claim Form is an essential document that ensures claimants can effectively communicate their needs and receive the benefits to which they are entitled.

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Combined Insurance

Claim Form A division of Chubb Insurance New Zealand Limited

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 [email protected]. 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.

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.

Page 1 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 offer 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 offer 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 offers 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 Officer 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 offers of products or services from Us or persons We have an association with, please contact the Privacy Officer by posting correspondence to Chubb Insurance New Zealand Limited, PO Box 734, Auckland; telephoning:

+64 (9) 3771459; or emailing [email protected].

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 Officer at the details above.

You also have a right to address Your complaint directly to the Privacy Commissioner by telephoning 0800 803 909, emailing [email protected] 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: [email protected]

Phone: COMBINED (266 246) (call free within NZ)

+64 9 520 9000 (if calling from overseas) Fax: +64 9 520 9009

Post: The Complaints Officer 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: [email protected]

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 Affairs. 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: [email protected]

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 2 of 7

Claimant to complete this page

SECTION 1

(Please print using BLOCK LETTERS)

IMPORTANT. Write your Account Number here

Office Use Only

Claimant’s Details

Mrs

Miss

Other:

Claimant's Full Name:

Date of Birth:

Height:

Weight:

Residential Address:

Postcode:

Postal Address (If different 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?

Yes

If Yes, please provide Family Policy Account Number:

It is our preference to make claims payments by Electronic Funds Transfer (EFT).

ADo you want us to make payments on this claim by EFT into your account?

Yes No

BIf Yes to ‘A’, is the account that you pay your premium from the Account you want us to pay your claim payments to?

Yes No

CIf No to ‘A’ and/or ‘B’, please provide name of preferred Financial Institution:

Account Name:

Bank

Branch Number

Account Number

Suffix

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?			Yes	No	Date:	/	/		Police Station:

	Was anyone charged by the Police?		Yes		No	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?								Yes	No
	(If Yes, please provide details - state types and quantities)

	Did you have a Blood Alcohol Test or Drug Test by the Police?					Yes	No		If Yes, what was the result?

8.	Were you transported to Hospital by Ambulance after the accident?						Yes	No
	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

Page 3 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?						Yes	No	(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?				Yes	No	(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?			Yes	No	(If Yes, please provide details)
Date(s):

Treatment Received:

Name of treating Medical Practitioner/Specialist:

Address of Medical Practitioner/Specialist who treated you:

Complete for Accident and Sickness

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?	Yes	No	(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 affected by any other long term or chronic disability?

Yes

(If Yes, please provide details)

20.Were you hospitalised?

Yes

(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?

Yes

No (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.

Yes

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

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 [email protected].

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	X	Date:	/	/
claimant:

Name of

Witness:

Signature of	X	Date:	/	/
Witness:

Page 5 of 7

		Medical Practitioner only to complete this section
	SECTION 2
		This section must be fully completed by a Legally Qualified Medical Practitioner, at the Claimant’s expense.

Please read carefully before completing this section.

Total Disability

The inability to perform each of the substantial duties of your business or occupation (usual activities if not employed).

Definitions

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.

Patient’s Full Name:		Date of Birth:	/	/
Patient’s Full Name:		Date of Birth:
1. Please tick whether claim is for:	Sickness	Injury
Diagnosis:

Cause:

2. If the patient is suffering 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?						Yes	No (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?	Yes	No	If No, please state date total disability began					Date:	/	/

6.	Has the patient ever had this condition before?	Yes		No
	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 affecting the present condition?						Yes	No
	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?		Yes	No
	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?		Yes	No	Date:	/	/
	Details of surgery:

10. Has the patient been referred to any other Medical Practitioner or Specialist?						Yes	No	(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?			Yes	No	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: (			)

Page 6 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?						Yes	No

13. Is there any further medical information relevant to this claim?

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.

Declaration

I/we confirm that to the extent I/we am/are aware, the information supplied in this form is true and correct.

Medical Practitioner’s Declaration				WE RECOMMEND THAT A COPY OF THIS FORM IS TAKEN FOR YOUR FILES.

		Date:	/	/	Provider Number:



		Qualifications:
		Qualifications:

		Address: (If not on stamp)

		Telephone Number: (If not on stamp) (			)

	MEDICAL PRACTITIONER’S	Email Address: (If not on stamp)
	STAMP REQUIRED

Full Name of the

Medical Practitioner’s:

Signature of the

Medical Practitioner’s: X

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 [email protected]

Website www.combinedinsurance.co.nz Postal Address Private Bag COMBINED Remuera Auckland 1541

Form Number: NZ00010 / ChubbNZ11-22-0721

Page 7 of 7

➤ PDF File

Form Specifications

Fact Name	Details
Contact Requirement	Claimants must contact Combined Insurance as soon as they are aware of a claim event.
Section Completion	Section 1 must be fully completed, and relevant documents should be attached to avoid processing delays.
Medical Practitioner’s Role	Only the claimant's Medical Practitioner should complete Section 2 and must sign the Claim Form.
Claim Submission Deadline	The Claim Form and supporting documents must be submitted within 30 days of the disability's commencement.
Claims Processing Timeline	Combined Insurance will acknowledge receipt of claims within 5 business days and determine acceptance within 10 business days.
Governing Law	Claims are governed by New Zealand law, particularly the Privacy Act and the Fair Insurance Code.

Combined Insurance Claim: Usage Guidelines

Completing the Combined Insurance Claim form requires careful attention to detail. Following the steps outlined below will help ensure that your claim is processed efficiently. Make sure to provide accurate and complete information to avoid any delays.

Begin by filling out Section 1 with your personal details. Use block letters and ensure all fields are completed to the extent relevant.
Attach any relevant invoices and documents that support your claim. This may include hospital statements, medical reports, or receipts.
Have your Medical Practitioner complete Section 2. They must fill it out fully and sign and date the form in the designated area.
Submit the completed form and all supporting documents within 30 days of the start of your disability. You can send it via post, fax, or email.
If applicable, provide details of any accidents or sickness in the relevant sections. Be specific about the nature of injuries or symptoms.
Ensure you have included any additional information required for specific benefits, such as proof of hospitalization or medical reports for fractures or cancer.
Keep a copy of the completed form and all documents for your records.
After submission, expect to receive an acknowledgment from Combined Insurance within 5 business days.

Once you have submitted the form, Combined Insurance will begin processing your claim. They may reach out for additional information if needed. Stay proactive in communication to ensure your claim is resolved promptly.

Your Questions, Answered

What is the Combined Insurance Claim Form?

The Combined Insurance Claim Form is a document that policyholders use to file a claim for benefits under their insurance policy with Combined Insurance, a division of Chubb Insurance New Zealand Limited. This form gathers essential information about the claim, including details about the insured event and supporting documentation to facilitate the assessment process.

How do I complete the Claim Form?

To complete the Claim Form, start by filling out Section 1 with your personal details, including your full name, date of birth, and contact information. Be sure to provide accurate and up-to-date information. In Section 2, your Medical Practitioner must fill out relevant details regarding your medical condition and sign the form. Attach any supporting documents, such as invoices or medical reports, to strengthen your claim.

What happens if I don’t complete the form fully?

If you do not fully complete the Claim Form, it may lead to delays in processing your claim. Combined Insurance will need to reach out to you for the missing information, which can prolong the assessment process. To avoid this, ensure that all sections are filled out accurately and completely before submission.

How long do I have to submit my claim?

You must submit your Claim Form along with all supporting documents within 30 days of the start of your disability or the event giving rise to the claim. If you fail to report your claim within this timeframe and the delay affects the ability to assess your claim, it may result in a delay or denial of payment.

What is the claims process after I submit my form?

Once Combined Insurance receives your completed Claim Form, they will acknowledge receipt within five business days. They will then identify your insurance policy and assign a claim number. Within ten business days, they will determine whether to accept your claim, provided they have all necessary information. If additional information is needed, they will inform you about what is required and how long it might take to resolve your claim.

Can I access the information used to evaluate my claim?

Yes, you have the right to access the information that Combined Insurance used to evaluate your claim. If you believe there are inaccuracies, you can request corrections. This transparency ensures that you are informed about how your claim is being assessed and allows you to address any concerns regarding the information held by the insurer.

What should I do if my claim is denied?

If your claim is denied, Combined Insurance will provide a clear explanation of the reasons for the denial. You have the right to access their Complaints and Disputes Resolution process. This process allows you to formally challenge the decision and seek further clarification or reconsideration of your claim.

What types of documentation do I need to attach to my claim?

The documentation required depends on the nature of your claim. For example, if you are claiming for hospitalization, include a copy of your hospital statement. If you are claiming for a fracture, attach a medical report verifying the fracture. Always refer to the specific instructions in the Claim Form for the necessary documentation related to your particular benefit.

How can I contact Combined Insurance for assistance?

If you have questions or need assistance while completing the Claim Form, you can contact Combined Insurance at 0800 COMBINED (266 246). Their representatives are available to help you with any queries regarding the claims process or the information required for your claim.

What should I do if I have a complaint about my claim?

If you have a complaint regarding your claim or the handling of your claim, you can follow the complaint handling procedure outlined in the Claim Form. Start by contacting Combined Insurance directly through their designated complaint channels. If you are not satisfied with the response, you can escalate the issue to their internal dispute resolution team or contact an independent external dispute resolution scheme.

Common mistakes

Incomplete Information: One of the most common mistakes is not filling out all required sections of the claim form. If certain sections are left blank or only partially completed, it can lead to delays in processing. Ensure that every relevant section is filled out accurately.
Missing Supporting Documents: Failing to attach necessary documents is another frequent error. Each claim type requires specific supporting documents, such as medical reports or hospital statements. Without these, the claim may be delayed or denied.
Incorrect Signatures: It's essential that the Medical Practitioner signs the form in the designated area. If the signature is missing or placed incorrectly, it can hinder the claim process. Double-check that all required signatures are present.
Late Submission: Submitting the claim form after the 30-day deadline can negatively impact the claim. It is crucial to send the completed form and all supporting documents within this timeframe to avoid any issues with the claim being processed.

Documents used along the form

The Combined Insurance Claim Form is essential for initiating a claim with Combined Insurance. Alongside this form, several other documents may be required to support your claim. Below is a list of commonly used forms and documents that can assist in the claims process.

Medical Report: This document provides detailed information from your medical practitioner regarding your condition. It verifies the diagnosis and may be necessary for certain claims.
Hospital Statement: If you were hospitalized, this statement outlines your admission and discharge dates. It may also include details about your treatment and is crucial for claims related to hospitalization.
Police Report: In cases of accidents, a police report may be required. This document contains official details about the incident, including any charges filed, which can support your claim.
Invoices and Receipts: Attach any relevant invoices or receipts for expenses related to your claim, such as transportation or lodging. These documents substantiate your financial claims.
Continuing Claim Form: If your disability is ongoing, this form must be completed by your medical practitioner during subsequent visits. It allows for continued assessment and payment of benefits.
Pathology Report: For claims related to cancer, a pathology report is necessary. This document confirms the diagnosis and may include details about the type of cancer.
Photographs: If claiming for a facial disfigurement benefit, photographs of the affected area may be required. This visual evidence can support your claim for compensation.

Gathering these documents can expedite the claims process and increase the likelihood of a successful outcome. Ensure all forms are filled out accurately and submitted within the required timeframe to avoid delays.

Similar forms

Insurance Claim Form: Similar to the Combined Insurance Claim Form, an insurance claim form is used to report a loss or damage for various types of insurance policies. Both require detailed information about the claimant and the incident that led to the claim.
Health Insurance Claim Form: This form is specifically designed for health-related claims. Like the Combined form, it asks for medical details, treatment information, and requires signatures from healthcare providers to validate the claim.
Auto Insurance Claim Form: When filing a claim for vehicle damage, this form collects information about the accident, vehicle details, and parties involved. It shares the requirement for timely submission and supporting documents, similar to the Combined Insurance Claim Form.
Life Insurance Claim Form: This document is used to claim benefits upon the death of the insured. It demands personal information and documentation to establish the claim, mirroring the thoroughness of the Combined Insurance Claim Form.
Disability Insurance Claim Form: Used to request benefits for disability, this form requires medical evidence and personal details. It parallels the Combined form in its need for verification by a medical professional.
Property Insurance Claim Form: This form is utilized to report damage or loss to property. Both forms require a clear description of the event and supporting documentation to substantiate the claim.
Workers’ Compensation Claim Form: This form is essential for employees seeking compensation for work-related injuries. It shares similarities with the Combined form in that it requires medical documentation and timely submission.
Travel Insurance Claim Form: Used to claim for losses incurred during travel, this form also requires detailed information about the incident and supporting documents, akin to the requirements of the Combined Insurance Claim Form.

Dos and Don'ts

When filling out the Combined Insurance Claim form, it is crucial to follow certain guidelines to ensure a smooth process. Below is a list of things you should and shouldn't do:

Do contact Combined Insurance as soon as you are aware of an event that may lead to a claim.
Do complete Section 1 in full and attach any relevant supporting documents.
Do have your Medical Practitioner fill out Section 2 and ensure they sign and date the form.
Do submit your claim within 30 days of your disability onset.
Do keep copies of all documents you send for your records.
Don't leave any sections of the form incomplete; missing information may delay your claim.
Don't submit your claim without the necessary supporting documents, as this may lead to rejection.
Don't wait too long to report your claim; delays can affect the outcome.
Don't provide false or misleading information, as this can result in denial of your claim.

Following these guidelines can help facilitate the processing of your claim and ensure that you receive the benefits you are entitled to. If you have any questions, reach out to Combined Insurance for assistance.

Misconceptions

Misconception 1: The Combined Insurance Claim form can be completed by anyone.

This is not accurate. Only your Medical Practitioner should fill out Section 2 of the form. Their signature and date are required for processing your claim.

Misconception 2: Submitting the claim form late will not affect my claim.

Submitting the claim form after 30 days may delay or affect your claim. Timely submission is crucial for a smooth claims process.

Misconception 3: I can provide incomplete information and still have my claim approved.

Incomplete information can lead to delays. It is essential to provide honest and complete details to facilitate faster processing.

Misconception 4: My claim will be processed immediately once submitted.

Claims are not processed immediately. Acknowledgment of receipt will occur within 5 business days, but determining the claim may take longer.

Misconception 5: I do not need to provide supporting documents.

Supporting documents are necessary for your claim. Relevant invoices and medical reports must be attached to substantiate your claim.

Misconception 6: I can claim benefits for future disabilities.

Benefits are only paid for losses that have already occurred. Claims for future disabilities cannot be processed until they are verified by your Medical Practitioner.

Misconception 7: I can access my claim information at any time without restrictions.

While you have the right to access information used in evaluating your claim, there may be specific procedures to follow. Always inquire about your rights and access methods.

Key takeaways

Here are key takeaways for filling out and using the Combined Insurance Claim Form:

Contact Combined Insurance promptly after an event that may lead to a claim. Provide accurate and complete information.
Complete Section 1 thoroughly and attach any necessary invoices or documents to support your claim.
Your Medical Practitioner must fill out Section 2 completely and sign the Claim Form.
Benefits are typically paid only up to the date your Medical Practitioner signs the Claim Form. Ongoing disabilities require additional forms.
Be prepared to provide more information if requested, or to undergo an independent assessment.
Submit the Claim Form and supporting documents within 30 days of your disability. Delays may affect your claim.
Combined Insurance will acknowledge your claim within 5 business days and will keep you updated every 20 business days.
You have the right to access information used to evaluate your claim and to correct any inaccuracies.
If your claim is declined, Combined Insurance will explain the reasons and inform you about the complaints process.

For assistance with the Claim Form or any questions, contact Combined Insurance at 0800 COMBINED (266 246).