Credit Life Disability Claim Form

Section A: Details of Insured

Section B: Nominated Credit Provider Details

Credit Provider Bank Account Details

Section C: Kindly provide us with the following

Diagnosis of patient’s condition

The Cause of the patient’s disability

Date of Diagnosis

Was the patient informed of the diagnosis?
YesNo

Details of complications or concurrent conditions

Date of first consultation and treatment with regards to the patient’s present medical condition

Date of last consultation and treatment with regards to the patient’s present medical condition

Names, Addresses and contact numbers of any other medical practitioners who may be consulted

Full details of treatment from the date of first consultation to the current date, the results, and the reasons, if any, for change

Please provide details of other information, which may be useful to the company in assessing this claim etc

Section D: Declaration

Section E: Supporting Documentation Required

Disability Claim Form

Copy of Loan Contract

Copy of Support 4 U Policy Certificate

Client/Borrower Statement from your Loan Management System

Copy of Policy Holder’s Identity Document

Medical Report(s) from the physician relevant to the Disability being claimed for

Ensuresure that the relevant claim form is completed by the attending physician

Investigations, laboratory tests, specialist reports etc

IMPAIRMENT is the alteration of normal functional capacity, that is, which functions is the person still able to do and which not, due to disease, and in assessment by medical means, after a diagnosis has been established, and appropriate and optimal treatment applied.

DISABILITY is the alteration of capability to meet the personal, social or occupational demands due to impairment, and is judged by non-medical means, that is in conjunction with his job description, policy disability clause condition and personal factors, such as education, experience etc.

For ease of reference we have provided the definitions as accepted by the insurance market of impairment and disability and would request that you do not comment on the nature of the occupational disability unless the details of the policy definition have been made available to you and such a decision specifically requested. As this decision may interfere with your doctor-patient relationship it is in your own interest not to make such comments.

We require an objective medical opinion of the impairment experienced by your patient, providing full details of all limitations in movement, use or restriction
The details of all treatment from the elementary to the most advanced will provide us with a full picture of the condition and it’s progression.

Thank you for our assistance in this claim.

POPI Act Disclosure and Permission:

(1) In line with the Protection of Personal Information Act no. 4 of 2013 I hereby give consent that all personal information supplied herewith may be used for the sole purpose related to the document intent herewith.

(2) I further consent that the data be used or exchanged with 3rd parties to validate information, fraud prevention, investigations, payments processing and product related marketing campaigns. I provide consent for Groups Are Us (PTY) Ltd to share my information with the external compliance officers for quality control and risk mitigating matters.

(3) Section 18 of the FAIS Act requires that records like client transactions, complaints, cancellations and financial records be kept for five (5) years. I understand that I can exercise my right to opt-out and avoid or stop any further use of my personal data within this disclosure after the record keeping requirement period is over.

(4) I acknowledge and understand that I can make contact with the Information Officer of Groups Are us (Pty) Ltd to lodge a complaint for any suspected abuse and/or
regulatory misconduct around my personal information processing or if personal information is being used for any reasons outside the intent of this document.

*For our privacy policy please refer or visit: www.groupsrus.co.za