Macquarie Life: Notification of claim

 

Notified by

Adviser name*
Member name*
Other
Relationship to Claimant*

Claimant details

Given names*
Surname*
Date of Birth*
Policy number(s)*

Claimant contact details

Street 1*
Street 2 
Suburb *
State *
Postcode *
Phone number *
Email address *

Claim details

Type of Claim (check all that apply)  
 
 
 
 
 
 
 
 
What is the cause of the claim? (check all that apply)  
 
 
 
 
   
Diagnosed condition
Date first saw medical practitioner for claimed condition
Last day at work
Expected return date of work

Medical Practitioners Details

* Name of treating doctor
Address of treating doctor*
Contact phone number*
Is this your usual doctor? Yes No
If no, details of usual treating doctor
Date first saw doctor for claimed condition
Next review date
   

Additonal Comments

Comments  
Name of person notifying
 

Verification

     Send Reset