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Blank Combined Insurance Claim PDF Template

The Combined Insurance Claim Form is a critical document for policyholders of Chubb Insurance New Zealand Limited, who find themselves in need of submitting a claim. This form is designed to streamline the process of claims submission by providing clear instructions on how to properly complete and submit the claim, ensuring that policyholders can efficiently provide all necessary information for the assessment of their claims. Completing this form accurately and in a timely manner can significantly expedite the claim review process. To learn more about how to fill out this form accurately, click the button below.

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Blank Combined Insurance Claim PDF Template

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Embarking on the journey of filing an insurance claim can often be viewed as navigating through a complex labyrinth, filled with specific procedures and meticulous details demanding attention. This is especially true for individuals preparing to complete the Combined Insurance Claim Form, a crucial document provided by Combined Insurance, a division of Chubb Insurance New Zealand Limited. The form is designed with the purpose of simplifying the claims process for policyholders, ensuring they provide comprehensive and accurate information to facilitate a swift assessment and processing of their claim. It's important for policyholders to contact the insurance company promptly upon the awareness of an event that may give rise to a claim, providing all relevant and up-to-date information. The form itself is divided into sections, with the first part requiring detailed information from the policyholder, including any supporting documents such as invoices or medical reports, and the second part to be filled out exclusively by the medical practitioner. The instructions stress the importance of honest and complete disclosures, outline specific guidelines on submitting claims for various benefits such as hospitalization, fractures, and transportation, and elaborate on the insurer's commitment to safeguarding the privacy of the claimants. Additionally, the document highlights the insurer's adherence to New Zealand's Fair Insurance Code and provides insights into the claims process, from the initial submission to the final resolution, including the potential for disputes and complaints. This comprehensive approach underscores the insurer's dedication to transparency and customer service, ensuring policyholders are well-informed and supported every step of the way.

Preview - Combined Insurance Claim Form

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 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.

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 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 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 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 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: 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 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: 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 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 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	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 claims@combined.com

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

Form Number: NZ00010 / ChubbNZ11-22-0721

Page 7 of 7

Download Combined Insurance Claim PDF Form

Form Data

Fact Name	Description
Timeliness for Reporting Claims	Claims must be sent within 30 days of the disability's commencement to avoid potential delays or impacts on the claim processing due to prejudiced assessment capabilities.
Claim Acknowledgment Period	Upon receiving a completed claim form, Combined Insurance will acknowledge receipt within 5 business days.
Claim Decision Timeline	Combined Insurance aims to determine the acceptance of a claim within 10 business days from when all necessary information is received.
Information and Documentation	The claim form requires personal details, accident or sickness details, and supporting documentation such as medical reports, invoices, and proof of expenses related to transportation, lodging, etc.
Governing Law and Compliance	Combined Insurance complies with New Zealand’s Privacy Act regarding the collection, use, and retention of personal information.

Instructions on Utilizing Combined Insurance Claim

Filing an insurance claim can often feel overwhelming, especially when dealing with the aftermath of an event that led to the necessity of the claim itself. Understanding the process and being prepared with all the required information will help ensure that the claim is processed efficiently and effectively. It’s essential to follow the instructions carefully and provide detailed, accurate information to support your claim. Here's a step-by-step guide to help you complete the Combined Insurance Claim Form.

Contact Combined Insurance as soon as possible to inform them about the event or circumstance that may give rise to a claim. Provide honest, complete, and relevant information.
Fill out Section 1 of the Claim Form in full, and attach any relevant invoices or documents that support your claim.
Have your Medical Practitioner complete Section 2 in full and ensure they sign and date the Claim Form in the appropriate place.
If your disability continues beyond the date your Medical Practitioner signs the form, obtain a Continuing Claim Form or Progress Form for them to complete on your next visit. Submit this for additional payments.
Submit the Claim Form with all supporting documents within 30 days of the commencement of your disability via post, fax, or email as directed on the form. Late submissions could affect or delay your claim.
Wait for an acknowledgment of your claim from Combined Insurance, which should arrive within 5 business days of submission. They will assign a claim number for reference.
Cooperate with any further information requests or independent assessments that Combined Insurance may require to process your claim.
Stay updated on the progress of your claim. Combined Insurance will communicate updates at agreed intervals until the claim is resolved.
Remember to exercise your rights to access information used in evaluating your claim or to correct any inaccuracies. Contact Combined Insurance if needed.
If dissatisfied with the claim outcome, you can access Combined Insurance’s Complaints and Dispute Resolution process for further assistance.

Each step in this process is designed to ensure that your claim is assessed accurately and promptly, allowing you to focus on recovery and moving forward. If you require assistance at any point, do not hesitate to contact Combined Insurance for support.

Obtain Answers on Combined Insurance Claim

How soon should I contact Combined Insurance after becoming aware of a claim?

You should contact Combined Insurance as soon as you become aware of any circumstance or event giving rise to a claim. Providing honest, complete, up-to-date, and relevant information promptly can expedite the assessment process.
What happens if I don't fully complete the Claim Form?

Incomplete submission of the Claim Form may result in processing delays. Missing information will require Combined Insurance to contact you, thus prolonging the time to settle your claim.
Who is responsible for completing Section 2 of the Claim Form?

Section 2 of the Claim Form must be completed by your Medical Practitioner in full and signed in the appropriate place. This information is critical for the assessment of your claim.
How are continuing benefits handled if my disability is ongoing?

If your disability continues beyond the date your Medical Practitioner signs the Claim Form, you will receive a Continuing Claim Form or Progress Form. Your Medical Practitioner must complete and sign this form. Payments can then be made for the ongoing disability up to the newly signed date.
What is the timeframe for submitting the Claim Form?

The Claim Form, along with all supporting documents, should be submitted within 30 days from the commencement of your disability. Late submissions might affect or delay the payment if they impact our ability to assess the claim.
How will I know that Combined Insurance has received my Claim Form?

Upon receipt of your completed claim form, Combined Insurance will acknowledge it within 5 business days. They will also assign a claim number for reference and inform you whether the claim has been accepted within 10 business days of having all necessary information.
What should I attach if I'm claiming a benefit for hospitalization?

If your policy covers hospitalization benefits, attach a copy of your hospital statement showing the admission and discharge dates. For claims involving intensive care or specific treatments like Covered Cancer, other pertinent documentation such as Pathology or Histopathology Reports should also be included.

Common mistakes

Filling out a Combined Insurance Claim Form requires attention to detail and a thorough understanding of the instructions provided. However, mistakes can occur, leading to delays or issues with the claims process. Here are five common mistakes people make when completing this form:

Not contacting Combined Insurance promptly after an event: Many people delay contacting their insurer after an event that may lead to a claim. Prompt communication is vital for a smooth process.
Incomplete information in Section 1: This section is crucial and must be filled out comprehensively. Skipping details or not attaching relevant invoices and documents can lead to delays as the insurer seeks the missing information.
Not having the Medical Practitioner complete Section 2 fully: Only the insured's Medical Practitioner should fill this out in detail, sign, and date it. If this section is incomplete or improperly filled, it can cause delays or issues with the claim.
Delaying the submission of the Claim Form: The form, along with all supporting documents, should be sent within 30 days of the disability's commencement. Late submissions might affect the assessment and payment of the claim.
Failing to cooperate with further requests for information: The claims process may require additional information from the claimant or the Medical Practitioner. Failure to provide requested information promptly can cause further delays.

To avoid these mistakes, it's essential to carefully read and follow the provided instructions, ensure all sections are fully completed with accurate information, and respond promptly to any further requests from the insurer.

Documents used along the form

When managing an insurance claim, particularly with a Combined Insurance Claim Form from Chubb Insurance New Zealand Limited, individuals might be required to compile and submit additional forms and documents for the claim to be processed accurately and efficiently. This portfolio of documents is crucial to substantiate the claim made and accelerate the approval process. Below is a list of supplementary documents usually associated with an insurance claim.

Hospital Statement: This document details the patient’s hospital admission and discharge dates, often necessary for claims related to hospital stays.
Medical Report: A detailed report from a medical practitioner verifying the nature and extent of injuries or illness, crucial for claims related to medical treatments.
Pathology, Histology, or Histopathology Report: These reports are essential for claims related to cancer diagnoses, proving the type and severity of the cancer.
Receipts for Medical Expenses: Original receipts from hospitals, pharmacies, and other healthcare providers are required to document the expenses incurred due to the illness or injury.
Police Report: Necessary for claims resulting from accidents, especially those involving motor vehicles, to verify the details of the incident.
Proof of Income: Documents such as pay slips or tax returns might be necessary for claims that include compensation for lost income.
Photographs: Visual proof of injuries or damage tied to the claim, which can include before-and-after shots if relevant.
Travel Expense Receipts: For claims that involve transportation or lodging benefits, corresponding receipts validate these expenses.
Medical Certificate: A document from a healthcare professional declaring the claimant’s health status, injuries, or disability, often required to validate claims related to physical conditions.
Continuing Claim Form or Progress Form: Used for ongoing claims, these forms are filled by the medical practitioner to update the insurer regarding the claimant’s condition and recovery progress.

To expedite the claims process, it's important for claimants to gather and submit the proper documentation timely and accurately. Submitting comprehensive and precise information helps avoid delays and ensures the claim is processed smoothly. Insurers, on their part, pledge to handle each claim with the urgency and attention it demands, sticking to the protocols that govern claims processing. This collaborative effort between claimant and insurer is essential for a satisfactory resolution to the claims process.

Similar forms

The Combined Insurance Claim form is a detailed document designed for insured individuals to report incidents and file claims. It shares similarities with various other documents, particularly those involved in the insurance and health industries. Here are ten similar documents and the ways in which they resemble the Combined Insurance Claim form:

Health Insurance Claim Form: Like the Combined Insurance Claim form, it’s used by policyholders to make a claim for covered medical treatments. Both forms require detailed information about the medical services provided and may request additional documentation, such as invoices or medical reports.
Auto Insurance Claim Form: This form is used after vehicle accidents and bears similarities in structure, requiring detailed incident information, third-party details, and supporting evidence such as police reports and repair estimates.
Travel Insurance Claim Form: It is similar in its need for comprehensive information regarding an incident that occurred while travelling, including medical expenses, lost luggage, or trip cancellations, echoing the necessity for documentation and detail found in the Combined Insurance Claim form.
Disability Insurance Claim Form: This document requests detailed medical information about the disability or illness preventing work, similar to the medical information section required in the Combined Insurance Claim form.
Workers' Compensation Claim Form: Like Combined Insurance's form, it is used by employees to claim benefits for injuries or illnesses related to their job. Both necessitate detailed descriptions of the incident, medical evidence, and an account of the inability to work.
Property Insurance Claim Form: Homeowners or renters file this in the event of property damage or loss, requiring detailed descriptions of the incident and itemized lists of losses or damages, akin to the detailed incident and treatment accounts in the insurance claim form.
Product Warranty Claim Form: Customers use this to claim under a product’s warranty. While focused on products rather than personal insurance, it similarly demands detailed descriptions of the issue and proof of purchase, paralleling the evidentiary requirements in insurance claims.
Life Insurance Claim Form: Filed by beneficiaries, it shares the need for detailed personal information, evidence, and descriptions of circumstances surrounding a claim, as seen in Combined Insurance's document.
Healthcare Provider Claim Form: Used by medical professionals to claim payment from insurance companies for services rendered to policyholders, requiring detailed treatment information that mirrors the detail needed in patient-submitted health insurance claims.
Dental Insurance Claim Form: Focused on dental treatments, it resembles the Combined Insurance Claim form in its requirement for specific treatment details, patient information, and supporting documentation like x-rays or treatment plans.

Each of these documents serves a specific purpose, often within the insurance realm, but they all share a common need for detailed incident descriptions, personal information, and supportive documentation to process a claim properly.

Dos and Don'ts

When preparing to complete the Combined Insurance Claim form, there are essential practices to follow and avoid for a smoother process and to ensure your claim is processed efficiently. Here's a guide to help:

Things You Should Do:

Report Promptly: As soon as you become aware of any event that might lead to a claim, contact Combined Insurance immediately. Providing honest, complete, and relevant information from the start can speed up the claims process significantly.
Complete Section 1 Thoroughly: Fill out every relevant part of Section 1 in detail, and attach all necessary documents, such as invoices or medical reports. Incomplete forms could delay the processing of your claim.
Have Your Medical Practitioner Fill Out Section 2: This section should be completed in full by your medical practitioner who must also sign and date the form. This ensures that your claim is based on professional medical assessment.
Submit Your Claim Form and Supporting Documents Promptly: Send your completed claim form along with all necessary supporting documents within 30 days of the event. Late submissions could affect the assessment and payment of your claim.

Things You Shouldn't Do:

Delay in Reporting Your Claim: Waiting too long to report your claim or to submit the claim form can prejudice the assessment process. Prompt communication is crucial for a smooth claims process.
Omit Information: Failing to provide all relevant details and omitting attachments like invoices, medical reports, or other required documentation can lead to unnecessary delays or even denial of your claim.
Let Non-Medical Practitioners Complete Medical Sections: Only a licensed medical practitioner should complete Section 2 of your claim form. Allowing others to fill in this section reduces the credibility of your claim.
Ignore Claim Progress Updates: Once your claim is submitted, keep in touch with Combined Insurance for updates. Ignoring communications or requests for additional information can stall the process.

Adhering to these guidelines when filling out the Combined Insurance Claim form will help ensure that your claim is processed accurately and promptly, providing the support you need when you need it most.

Misconceptions

When navigating the complexities of filing claims with insurance companies, it's easy to encounter misconceptions, particularly concerning the Combined Insurance Claim Form provided by Combined Insurance, a division of Chubb Insurance, in New Zealand. Understanding these misconceptions is crucial for a smooth claims process. Here are seven common misunderstandings explained:

Misconception 1: All sections must be filled by the claimant personally.
While it's imperative that the claimant provides comprehensive and accurate information in Section 1, Section 2 must be completed by the Medical Practitioner treating the claimant. This ensures that medical information is accurately reported directly by a healthcare professional.
Misconception 2: Benefits are paid in advance based on estimated recovery times.
Insurance is designed to cover losses that have already occurred. Therefore, Combined Insurance pays benefits up to the date the Medical Practitioner signs the claim form, not in advance. For ongoing disabilities, a Continuing Claim Form or Progress Form will need to be submitted for further payments.
Misconception 3: Submission of a claim form is sufficient for processing.
Alongside the claim form, relevant supporting documents such as invoices, medical reports, and proof of hospital stays must be attached. Failure to include all necessary documentation could delay the processing of the claim.
Misconception 4: Claims can be submitted at any time without repercussions.
Claims should be reported within 30 days of the disability's commencement. Delaying beyond this period could prejudice the assessment process, potentially affecting or delaying the payment of the claim.
Misconception 5: The claim process is long and doesn't require updates.
Combined Insurance acknowledges receipt of claims within 5 business days and strives to decide on claims within 10 business days, providing updates every 20 days or at agreed intervals until the claim is resolved.
Misconception 6: Denied claims cannot be contested.
If a claim is declined, either partially or in full, claimants are informed of the reasons and can access the company's Complaints and Disputes Resolution process for further review or contestation of the decision.
Misconception 7: Personal information submitted is used only for claim assessment.
While the primary purpose of collecting personal information is to assess and manage the claim, Chubb may also use this information for marketing or improving services unless expressly declined by the claimant.

By clarifying these misconceptions, claimants can navigate the claims process more effectively, ensuring a smoother and more efficient experience with Combined Insurance.

Key takeaways

Filling out the Combined Insurance Claim form accurately and promptly can significantly influence the processing time and outcome of your claim. Here are ten key takeaways to ensure a smooth claim process:

It is crucial to contact Combined Insurance as soon as possible after an event that may lead to a claim, providing honest and complete information.
Ensure to complete Section 1 fully and attach any relevant invoices and documents to avoid delays.
Only your Medical Practitioner should fill out Section 2, including their signature and the date, to attest to your condition.
Remember that benefits are paid up to the date your Medical Practitioner signs the form, not for future disabilities not yet occurred.
Be prepared that additional information might be requested by Combined Insurance or that they may require an independent assessment to support your claim.
Send your claim form and supporting documents within 30 days of your disability, using the provided post, fax, or email details to avoid any issues with claim acceptance.
Understand the Claims Process steps, including acknowledgment of the claim, the assignment of a claim number, and the timeline for determination.
You have the right to access information related to your claim and request corrections on any inaccuracies found within.
In case of claim rejection, Combined Insurance will clearly explain the reasons, and you can access their Complaints and Disputes Resolution process.
For specific benefits such as hospitalization or fracture benefits, ensure to attach the required specific documents such as hospital statements or medical reports to substantiate your claim.

By paying close attention to these details and understanding the importance of each requirement, claimants can navigate the process more effectively, helping ensure claims are processed as quickly and smoothly as possible.

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