Income Protection Benefit Guide - QSuper Guide - Education Queensland
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
QSuper Guide
Income Protection
Benefit Guide
Issued: 23 January 20182 Income Protection Benefit Guide Contents Your income protection insurance 3 How do I apply? 5 How is my benefit paid? 6 Review and appeal process 7 Income Protection Benefit Application form
3
Income Protection Benefit Guide
Your income protection insurance
From 1 July 2016 we’ve got some new insurance arrangements in place to give you even greater peace of mind.
When it comes to determining what terms and conditions your claim will be assessed against, what’s important is not the date you make the
claim, but what’s known as the date of disablement. Even if you submit your claim from 1 July 2016, if the date of disablement was on 30 June
2016 or earlier, your claim will be assessed based on the level of cover and the terms and conditions that applied at the date of disablement.
About this guide
This guide explains what you need to do to make a claim for income protection benefits. If you’re a QSuper member with income protection
you might be eligible to receive a regular income for up to two or three years (depending on your employment arrangements and date of
disablement) if you’re temporarily unable to work due to an illness or injury. If you’ve personalised your cover, you may be entitled to income
protection benefits up to five years or to age 65, depending on the cover you’ve chosen. However if you have a Defined Benefit account, your
maximum income protection cover is up to two years.
Overview of your income protection cover
Here’s a quick reference to your default income protection cover. If you were a member before 1 July 2016 and previously cancelled cover,
default cover is not automatically applied.
Default cover from 1 July 2017
I work for Waiting and benefit periods Your benefit
The Queensland Government as a Accrued sick leave plus 14 days and payable If you are aged 16-64 we’ll pay 87.75% of
permanent or temporary employee for up to three years. your insured salary (including a Contribution
and make standard contributions to my Replacement Benefit of 12.75% of insured
Accumulation account. salary¹).
(If you’re a Member of the Legislative Maximum benefit limits apply.
Assembly, you aren’t eligible for income
protection cover.)
A default employer, or the Queensland 90 days or your accrued sick leave, whichever If you are aged 16-64 we’ll pay 87.75% of
Government as a permanent or temporary is greater, and payable for up to three years. your insured salary (including a Contribution
employee and don’t make standard Replacement Benefit of 12.75% of insured
contributions. salary¹).
Maximum benefit limits apply.
The Queensland Police Service as a police Accrued sick leave plus approved If you are aged 16-64 we’ll pay 87.75% of
officer. Queensland Police Service sick leave bank or your insured salary (including a Contribution
180 days, whichever is greater, and payable Replacement Benefit of 12.75% of insured
for up to two years. salary¹)
Maximum benefit limits apply.
A default employer or the Queensland You’re not automatically covered with default income protection cover, however you may
Government as a casual employee, or my be able to apply for income protection insurance if you’re eligible.
account was opened as either:
• I have applied for an Accumulation account
direct with QSuper (not through my
employer)
• A spouse of a QSuper member, or
• A result of a family law split
or
• I have an Income account, and an
Accumulation account was opened
for me with a contribution (including
consolidation from another fund).
1 Insured salary is your salary on which employer contributions are paid to QSuper and for the avoidance of doubt employer contributions do not include salary sacrifice contributions. For the
purpose of claims, insured salary will be calculated as at the date of disablement or, if you are gainfully employed on a casual basis, an averaged amount based on the period of 3 months prior
to the date of disablement (or over your most recent period of employment, if shorter).4
Income Protection Benefit Guide
If you’ve personalised your income protection cover, your waiting You should also know that if your condition is linked to an illness or
period, and/or benefit period and the benefit payable will be as injury where the date of disablement was before 1 July 2016 and
per your approved application. You can find this by logging onto you start to receive an income protection benefit payment, the
Member Online. (All benefits are subject to benefit cap limits.) maximum benefit period available will be two years and not three.
One thing to note - if you’ve previously received an income
protection benefit from QSuper and you need to make a claim for What about pre-existing conditions and other
the same or a related condition, your maximum benefit period will exclusions?
be reduced by the total number of weeks you received a benefit
from all previous claims related to that condition. Some of our cover comes with what’s known as a pre-existing
exclusion period, which is the period during which we won’t pay
an insurance benefit if the illness or injury you’re claiming is related
What if my date of disablement was before to a pre-existing condition.
1 July 2016?
If your date of disablement is on or before 30 June 2016, a five year
If you were a QSuper member before 1 July 2016 and your claim pre-existing exclusion period may apply.
relates to a date of disablement prior to 1 July 2016, your claim will
From 1 July 2016, default income protection cover has no pre-
be assessed under the terms and conditions that applied under
existing exclusion period provided you’re At Work on the day cover
your previous insurance arrangements.
starts (some exceptions apply).
Cover overview (if membership and date of disablement is prior In all cases, where a pre-existing exclusion period applies and
to 1 July 2016) you’re not At Work on the day the pre-existing exclusion period
expires, the pre-existing exclusion period will continue to apply
Waiting and until you have been At Work for 30 consecutive days.
I work for Your benefit
benefit periods
There’s more detailed information about pre-existing exclusion
The Queensland 14 days after you We’ll pay 75% of periods and other exclusions and how they apply refer to the
Government or use up all your your salary1 for up to Accumulation Account Insurance Guide.
a related entity paid sick leave, two years. We’ll also
employer as and your employer keep paying your
a permanent approves sick leave super contributions
or temporary without pay. of 17.75% of your
employee and Payable for up to salary.1
make standard 2 years.
contributions to
my Accumulation
account. (If you’re
a member of
the Legislative
Assembly you aren’t
eligible for income
protection cover.)
A non-Queensland 30 days of being We’ll pay up to
Government or totally unable 75% of your earned
related entity to perform your income up to
employer and occupation. a maximum of
you have income Payable for up to $25,000 per month.
protection cover. 2 years. Your cover is made
up of units with
each unit being
worth $1,000 per
month.
Police officers An income protection benefit is not
provided by QSuper
1 The salary used for the purpose of calculating your income protection benefit is your
salary for superannuation purposes.5
Income Protection Benefit Guide
How do I apply?
How do I apply for an income protection What if I’m working higher duties when I make
benefit? a claim?
Like most insurance claims, there’s some paperwork you need We do recognise higher duties, but just bear in mind you need to
to complete to apply for QSuper income protection benefit. You have been working in the position continuously for at least
need to: 12 months to have your benefit calculated at the higher salary
if you’re an Accumulation account holder. For Defined Benefit
• complete the three parts of the Income Protection Benefit Claim
account holders, you need to have been working in the
form at the back of this guide
higher-paid position for at least 12 months at the annual
• a ttach copies of any medical documents you already have on review date of 1 July.
your condition
• provide details on your work history and your income Let us know if your situation changes
• complete a Tax File Number Declaration form (you can get this You must notify QSuper if you:
from the ATO, newsagents, your employer, or call us and we’ll • r eturn to work or start new employment
send you one). Just remember that if you don’t provide your TFN,
your benefit might be taxed at a higher rate. • s tart an approved graduated return to work program
It’s important you know that you need to cover any costs charged • t ake any leave other than approved sick leave without pay
by your doctor to complete the Doctor’s Statement (Part C) of the • c ease to be an Australian Resident
Income Protection Benefit Claim form.
• intend to live outside Australia for greater than 6 months
We’ve tried to make claiming as simple as possible, but please get
in touch with us if you need any help completing the form. • e arn additional income
When you complete this form, remember to include important • engage in a business or occupation.
information that’s relevant to your claim. If you provide information To prevent overpayment of your benefit, it’s important that you
that’s not accurate or true, we might have to reduce the amount of notify us as soon as possible if any of the above occurs. If there is
income protection we pay you, or even stop your benefit and ask any overpayment of benefits we will ask you to repay QSuper.
you to repay QSuper for any overpayments.
Please send your completed paperwork to us at What happens if my condition becomes
QSuper, Claims Operations, permanent?
GPO Box 200,
Brisbane Qld 4001. If you become permanently disabled your income protection
benefit will stop, unless you’ve personalised your income
How do you assess my claim? protection cover to a 5 year period or to age 65. Then the income
protection cover will continue on that basis.
We work as hard as we can to assess your claim as quickly as
possible. Once we receive all the necessary paperwork from you,
you’ll be allocated a claims manager and they’ll contact you to talk
you through the claims process and answer any questions you
might have about your claim.
If we need further medical information from you, we might ask you
to provide a medical report about your medical history. We’ll cover
costs to get this additional medical information.
If your claim isn’t approved, we’ll send you a statement explaining
the reasons for our decision. We explain on page 7 of this guide
what you can do if you’re not happy with our decision.6
Income Protection Benefit Guide
How is my benefit paid?
Once we approve your claim, payments will be made into your If your claim relates to an illness or injury which occurred before
bank, credit union or building society account. 1 July 2016, reasons we might stop paying your benefit include
that you:
If you have an Accumulation account and salary-based income
protection cover, your income protection payments include a • a re no longer on approved sick leave without pay
contribution replacement benefit (CRB) of 12.75% of your insured
• d
on’t provide medical information we’ve requested
salary which is paid to your Accumulation account.
• d
on’t attend a medical assessment we’ve arranged
If you have a Defined Benefit account, your super continues to
grow while you’re receiving an income protection benefit (in the • s tart working your normal working hours again
same way it would if you were working).
• r eceive WorkCover benefits
Please remember to make other arrangements for any other
• a re paid for the maximum two year benefit period
payments that are automatically taken out of your pay such as
private health insurance premiums, child support or voluntary • c hange your employment status to casual
super contributions while you’re on income protection.
• s top working for an eligible QSuper employer
If you were a member before 1 July 2016 and your claim relates to
• if you are employed by the Queensland Government, you no
an illness or injury which occurred before 1 July 2016 and you were
longer meet the definition of temporary disablement. If you are
working for the Queensland Government or a related entity, your
not employed by the Queensland Government, you no longer
approved income protection payment will be backdated to the
meet the definition of Total Disability or Partial Disability.
start of your third week of sick leave without pay. Payments will be
made weekly and super contributions of 17.75% of your salary will
be made while you’re receiving income protection. What do I need to do while I’m receiving an
If you were a member before 1 July 2016 and your claim relates to
income protection benefit?
an illness or injury which occurred before 1 July 2016 and you’re While we’re paying you an income protection benefit we might
working for someone other than the Queensland Government or ask you to:
a related entity employer, payments for approved claims will be
backdated to the end of the 30-day waiting period. We’ll pay you • g
et medical report forms completed on a regular basis by your
monthly, in arrears. GP or medical specialist
• g
et detailed medical reports (from your GP or medical specialist)
Are there any reasons you might stop my
• a ttend independent medical or other assessments by specialists
income protection benefit? we nominate (your employer might also request this)
Yes, there are a number of reasons we might stop paying your • h
ave an interview over the phone or in person with our staff or
benefit. If your date of disability occurs after 30 June 2016 the agent/s
reasons include:
• p
articipate in rehabilitation or return to work programs.
• y ou no longer meet the definition of total and temporary
disablement or partial and temporary disablement This just helps us work out if you’re still eligible to continue to
receive income protection.
• you turn 65 (or 60 if you’re a police officer)
• you come to the end of your benefit payment period
• you’re determined by the Board to be suffering a total and
permanent disablement or to have a terminal illness, unless you
have a 5 year or to age 65 benefit period
• if it is determined your condition is a pre-existing condition, and
you have a pre-existing exclusion period attached to
your cover
• y ou become engaged in a new business or occupation (unless it
is part of an agreed graduated return to work program)
• y ou stop following the advice of an appropriate medical
practitioner
• you choose not to participate, or to continue to participate, in an
approved rehabilitation or retraining program7
Income Protection Benefit Guide
Graduated return to work program Additional info about this guide
As you recover from your illness or injury, you might ease back Make sure you read the Accumulation Account Insurance Guide and
into work as part of a graduated return to work program. If this this guide before you complete the Income Protection Benefit Claim
happens, your employer will pay for the hours you work, and we’ll form that’s attached to the guide. And keep the guide somewhere
pay a percentage of the difference between your insured salary handy in case you need to refer to it.
(or pre-disability income if your cover is in units) and your reduced
To make a claim you need to complete all three parts of the Income
salary.
Protection Benefit Claim form:
So even if you return to work you’ll still receive a partial benefit if
• the member statement (Part A) needs to be completed by
you continue to be disabled. For example if you return to work at
you, and make sure you attach all available medical certificates
40 per cent of your insured salary (or pre-disability income) we will
describing your illness or injury and any other relevant medical
pay you 60 per cent of your income protection benefit.
information along with details of any additional income or
To help you further, if your claim relates to a date of disablement earnings from other employment or any business you may be
on or after 1 July 2016, and you return to work for at least involved in
20 per cent of your substantive hours you may be eligible for the
• the employer’s statement (Part B) needs to be completed by
graduated return to work additional payment for a period of up to
your employer
eight weeks. This benefit may increase your total benefit payment.
For more details about the calculation refer to the Accumulation • the doctor’s statement (Part C) needs to be completed by your
Account Insurance Guide. Graduated return to work additional medical practitioner or specialist.
payments will end as soon as:
It’s important the claim form is completed in full before it’s sent to
• y ou stop participating in an approved graduated return to work us or your claim could be delayed.
program or
We can only pay your benefit into your bank, credit union or
• you return, or are able to return to work at your substantive hours building society account. This means we can’t pay it into a business
or or loan account. You should know that if you provide incorrect
details, there could be a delay in your payment or a loss of interest,
• t he graduated return to work additional payment has been paid
and we can’t accept responsibility for this.
for eight weeks.
Review and appeal process
What if I’m not happy with the decision? What is the Superannuation Complaints
We understand not everyone will be happy with the decisions Tribunal (SCT)?
made about their claims and you’re welcome to lodge an appeal The SCT is an independent tribunal set up by the Commonwealth
for review by QSuper. Send your appeal in writing to: Quality and Government to review complaints relating to decisions made by
Compliance, Operations, QSuper, GPO Box 200, Brisbane Qld 4001. super funds.
Remember, you need to cover any costs to obtain medical reports
to support your appeal. But please bear in mind you need to use our internal appeal
process before going to the SCT. If you’re not happy with the
If you’re still not satisfied with the review decision, you can lodge a review decision or we haven’t contacted you within 90 days of
complaint with the Superannuation Complaints Tribunal. The SCT lodging your appeal, call the SCT on 1300 884 114. They’ll let you
imposes time limits within which to lodge a complaint with them. know if they can deal with your complaint and the information
Please contact the SCT directly to ascertain your eligibility to lodge you’ll need to provide. You can visit the SCT website at sct.gov.au
a complaint. for further information.8 Income Protection Benefit Guide
QSuper Form Please complete in block letters, in blue or black ink.
1
Income Protection Benefit Claim
(Part A) – Member Statement
Who needs to complete this form?
You need to complete this part of the claim form to apply for income protection. We need detailed information about your job and your
illness or injury to be able to assess your claim. And please make sure you provide your medical practitioner’s details in case we need to get in
touch with them for more information. If you need any help completing this form, please give us a call.
1 Personal details You can find your client 2 Details of your medical condition
number on your annual
Client number statement or by logging Please attach copies of any medical evidence you already have
in to Member Online. on your illness or injury, and any other relevant information.
Name of your illness or injury (please provide a detailed description)
Title Given names
Surname
What was the cause of your illness or injury?
Previous name1 (if we know you by another name)
Date of birth (dd/mm/yyyy) Home phone number Are you receiving, or are you willing to receive, appropriate
medical care that’s recommended by your treating medical
practitioners?
Mobile phone number
Yes No
What treatment are you currently receiving?
Email address
When did you start your
Residential address treatment? (dd/mm/yyyy) Frequency
When was your illness first diagnosed or date you were injured?
(dd/mm/yyyy)
State Postcode
Postal address As above
When did you first see a doctor about your illness or injury?
(dd/mm/yyyy)
State Postcode When did you first stop working because of your illness?
(dd/mm/yyyy)
Name of your employer Payroll number
Have you started a graduated return to work program? If yes, please
HR/payroll contact name HR/payroll contact number specify the date this started.
Yes No
Are you employed or self-employed in any other role?
If yes, please provide details.
Have you returned to normal work duties?
Yes No
Yes No
If yes, tell us the date you returned to normal duties. (dd/mm/yyyy)
Have you been hospitalised for this condition?
Yes No
If yes, please make sure you provide us with a copy of the discharge
summary from the hospital.
1 If your name has changed and you work for the Queensland Government or related entity
employer, let your payroll office know and they’ll then let us know. Otherwise, please send us
a certified copy of either a marriage certificate or other legal change of name document.2
Income Protection Benefit Claim (Part A) – Member Statement
3 Your job details and employment history
Please tell us your capacity to do the following activities: Position/title
Can you dress yourself? (e.g. putting on and taking off clothes)
Yes No
Please describe your job in detail, including all of your duties and
If no, please describe the help you need and how you’re limited. responsibilities (and attach a position description and a copy of your
resume if possible).
Can you bathe yourself? (e.g. washing and showering)
Yes No
Please describe the help you need and how you’re limited.
If your job involves manual handling, please provide details of the types
Can you use the toilet by yourself, including getting on and off? of items you might lift/push/pull/carry, the physical demand of these
tasks and how often you do these tasks.
Yes No Lift (floor to waist)
Please describe the help you need and how you’re limited.
Lift (knee to shoulder)
Are you mobile? (e.g. walking, getting in and out of a chair or bed)
Yes No
Lift (waist to overhead)
Please describe the help you need and how you’re limited.
Push/pull
Can you feed yourself? (e.g. getting food from a plate to your mouth)
Yes No
Carry
Please describe the help you need and how you’re limited.
What duties are/were you able to do?
Can you do housework? (e.g. cooking and cleaning)
Yes No
Please describe the help you need and how you’re limited.
Are you able to drive? What duties are/were you prevented from doing?
Yes No
If no, please provide details.
Do you take care of children or other dependants? What educational qualifications, degrees and/or certificates
(including first aid and OHS) do you hold? Please include the year you
Yes No achieved these when providing details below.
Please describe your hobbies/interests/social activities. Secondary school
(e.g. year 10, year 12)
Tertiary (university or
technical college)
Does your condition affect your ability to do these activities? Post-graduate
Yes No
TAFE
If yes, please describe how you’re affected.
Other
Please provide your treating doctor’s details below.
Name
Phone number
Email address3
Income Protection Benefit Claim (Part A) – Member Statement
What specific work skills do you have (for example, Another insurance policy
management/supervision, retail, computer skills)? Income amount (gross) Frequency1
$
Please give details of previous employment (approximate dates are fine). Date payment started Date payments stopped
(dd/mm/yyyy) (dd/mm/yyyy)
Position/title Employer
Date paid
Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Lump sum benefits (dd/mm/yyyy)
$
Please describe all your duties and responsibilities.
Pension Scheme
Income amount (gross) Frequency1
$
Position Employer Date payment started Date payments stopped
(dd/mm/yyyy) (dd/mm/yyyy)
Start date (dd/mm/yyyy) End date (dd/mm/yyyy)
Date paid
Lump sum benefits (dd/mm/yyyy)
Please describe all your duties and responsibilities. $
Other (please specify)
Provide details of other sources of income which may include:
motor accident compensation, Social Security, Statutory or other
If you’ve received an income from any of the sources we list below, government payments.
please let us know the income, how often you receive it, the date
payment started and any lump sum payments below. Date paid
Lump sum benefits (dd/mm/yyyy)
Employer or business
Income amount (gross) Frequency1 $
$ Income amount (gross) Frequency1
Date payment started Date payments stopped $
(dd/mm/yyyy) (dd/mm/yyyy)
Date payment started Date payments stopped
(dd/mm/yyyy) (dd/mm/yyyy)
Date paid
Lump sum benefits (dd/mm/yyyy)
Date paid
$ Lump sum benefits (dd/mm/yyyy)
Workers’ compensation $
Income amount (gross) Frequency1
$ 4 Other entitlements
Date payment started Date payments stopped
(dd/mm/yyyy) (dd/mm/yyyy)
Have you claimed, or do you plan to claim, a benefit from WorkCover
for this illness or injury?
Date paid Yes No
Lump sum benefits (dd/mm/yyyy)
Please tell us the start and end dates of the WorkCover claim period.
$ Start date (dd/mm/yyyy) End date (dd/mm/yyyy)
Department of Human Services
Income amount (gross) Frequency1
If you’re claiming WorkCover, please tell us your:
$
WorkCover case manager’s name
Date payment started Date payments stopped
(dd/mm/yyyy) (dd/mm/yyyy)
WorkCover case manager’s
phone number WorkCover claim number
Date paid
Lump sum benefits (dd/mm/yyyy)
$
1 Weekly, fortnightly, or monthly4
Income Protection Benefit Claim (Part A) – Member Statement
5 Details of earnings before your illness or injury 7 Receiving your payment
(complete this section if you don’t work for
We can only make payments into an Australian bank, credit union
the Queensland Government) or building society account that’s in your name or a joint name
This means we can’t make payments into a business, trust or loan
What was your income (gross) prior to your account.
illness or injury? $
What was your base salary (gross) prior to your You should know that if you provide incorrect details, there could
illness or injury? $ be a delay in your payment or a loss of interest, and we can’t
accept responsibility for this.
Please provide details of your packaged salary below. (including base
salary, fees, and regular bonuses, allowances, overtime earnings and Name of bank, credit union or building society
commissions)
Branch (BSB) number Account number
6 Please complete if you’re self-employed
Account name
What income did your business earn in the last 12 months, as a direct
result of your physical exertion or activity through usual occupation?
Signature
Gross income from occupation $
Expenses $
Date (dd/mm/yyyy)
What were your income and expenses for the last 12 months
(pre-disability)?
Gross income from occupation $
Expenses $
What were your income and expenses for the last 24 months
(pre-disability)?
Gross income from occupation $
Expenses $5
Income Protection Benefit Claim (Part A) – Member Statement
8 Declaration and authorisation
• I’m the person named on this form or have power of attorney I agree that the individuals and organisations listed below can have
to act on the member’s behalf.1 access to my personal and medical information so that they can
• I confirm the information provided in this form is true and investigate and assess my claim:
correct, and I haven’t withheld any information that’s relevant • Workers’ compensation
to my claim.
• CTP insurer
• I agree to provide all medical information and undertake any
• Federal and State Government agencies including the
medical or occupational assessments requested by QSuper.
Department of Human Services and the Department of
• I understand I can’t receive an income protection benefit from Veterans’ Affairs
QSuper and compensation from WorkCover for the same
• my employer (only with my written consent)
period.
• my accountant
• I understand that if I am granted compensation from
WorkCover for the same period, I may be asked to pay back • my doctors, specialists and their agents
QSuper the income protection benefits paid to me during • QSuper
that time. • QSuper’s insurers
• I authorise any insurer (including workers’ compensation/CTP • QSuper’s appointed assessor which may be located overseas in
insurer), government agencies (including the Department of North America or the European Union.
Human Services and the Department of Veterans’ Affairs), my
employer, accountant or other relevant holder of information Name
to release to QSuper or its insurers2 information they might
need to assess my claim.
• I understand that a photocopy of my authority is considered as Signature
valid as the original.
• I authorise QSuper to refer to any statements that have been
made in connection with my application for insurance and
any medical reports to other entities involved in providing or Date (dd/mm/yyyy)
administering my insurance (for example reinsurers, third party
administration or specialist claims providers and legal advisers)
or persons appointed to obtain financial, employment or
medical related information in support of the assessment of If we need to contact you about this form, tell us which
my claims from any other entity holding information on me. way you’d prefer to be contacted?
• I consent to any sensitive information such as medical
information collected in this form being used by the QSuper Mobile Home phone Email
Board and its insurers1 and any of its authorised service
providers for the purposes of assessing my eligibility for
personalised cover and for the assessment or investigation of
any future claims made in relation to such cover.
• I have read QSuper’s Your Privacy factsheet and I understand
how QSuper will collect, use and disclose my personal
information to relevant to this claim.
1 If you’re signing as a power of attorney and you haven’t already given us a certified copy of
your power of attorney documentation, please attach it to this form.
2 QSuper’s insurers include TAL Life Limited, QInsure, OnePath and Suncorp.6
Income Protection Benefit Claim (Part A) – Member Statement
Checklist
Make sure you use this checklist to check you’ve completed the
claim form and you have all the supporting documents ready to
send us.
I’ve provided all the relevant information in section 1.
Yes No
I’ve provided details on my condition in section 2 and attached
copies of any medical evidence I already have on my condition
(and any other relevant information).
Yes No
I’ve completed my job details and employment history in section 3
(and section 5 for non-Queensland Government employees).
Yes No
If I’m claiming any other entitlements, I’ve provided details in
section 4.
Yes No
I’ve signed the QSuper declaration in section 7.
Yes No
I’ve provided details of my bank account in section 7 and
have attached a copy of my bank, credit union or building
society statement.
Yes No
I’ve provided a completed Tax File Number Declaration form.
Yes No
The information you’ve provided will be used to assess your
benefit entitlement for insurance. You should keep a copy
of your completed form and this guide as you may want to
refer to it in the future.
Where do I send the form?
Once you’ve completed the form and attached any
necessary documents, send it to us at QSuper, Insurance
Operations, GPO Box 200, Brisbane Qld 4001.
Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Postal address GPO Box 200 Brisbane Qld 4001 ABN 60 905 115 063
Telephone 1300 360 750 (+617 3239 1004 if overseas) Fax 1300 242 070 SFN 261041941
Monday to Thursday 8:30am to 5:00pm AEST Website qsuper.qld.gov.au CNC-1135 01/18 IB29
Friday 9:00am to 5:00pm AEST
This form and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). We take the privacy of your personal information very
seriously. We’re collecting personal information from you so we are able to assess your claim and are authorised to do this under the Superannuation (State Public Sector) Act 1990. We may also
collect information from your employer, government agencies, other superannuation funds, anyone you authorise and if it is required or authorised by law. We may disclose your information to
your employer, authorised service providers (including QInsure Limited ABN 79 607 345 853 AFSL 483057 and any of its authorised service providers), other superannuation funds and government
agencies and to third parties if we need to, if you’ve given consent to the disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet
from our website or call us on 1300 360 750 and request a copy. The information outlined in this form is general information only and doesn’t take into account your personal objectives, financial
situation, or needs. Before you make any decision regarding a QSuper product you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy.
© QSuper Board 2018QSuper Form 1
Income Protection Benefit Claim
(Part B) – Employer’s Statement
Who needs to complete this form?
This section of the claim form needs to be completed by your employer (HR or payroll office staff). Please ensure all questions are answered
before you send it to us.
1 Employee information 3 Employment information
Title Given names Does your employee work:
Full time
Surname
Part-time p/t fortnightly ratio
Casual
Date of birth (dd/mm/yyyy) Payroll number
Contractor contract end date (dd/mm/yyyy)
Position/job title When did your employee last attend work? (dd/mm/yyyy)
Place of employment and region When did they start sick leave? (dd/mm/yyyy)
What date was all accrued sick leave exhausted? (dd/mm/yyyy)
2 Salary information
Has your employee received other paid leave since all accrued sick
leave was exhausted?
What was your employee’s full time salary at 1 July before they went
on sick leave without pay (SLWOP)? Yes No
Date (dd/mm/yyyy) Salary If yes, what date does this cease?
1 July 20 $ per fortnight
What was your employee’s full time salary prior to starting sick leave? Employer rehabilitation contact name
Date (dd/mm/yyyy) Salary
$ per fortnight Phone number
Salary: When you provide your employee’s salary, it needs to
be their remunerated salary upon which the superannuation Email address
contribution is calculated.
If your employee works part-time, please provide us with their
full-time salary and indicate the part-time ratio in section 3. Preferred method of contact?
What was the employer paid Superannuation Guarantee Email Phone
Contribution (SGC) rate for your employee?
Who else, apart from employer rehabilitation contact above, should
% be advised upon assessment of claim?
Is your employee paying child support? Name/s
Yes No
Position/Job Title Phone number
Email address2
Income Protection Benefit Claim (Part B) – Employer’s Statement
4 Additional comments Additional information about this form
Please supply any information that clarifies or supports this As the employer, you need to complete this employer’s
Employer’s Statement. statement for any employee who is covered by QSuper’s income
protection insurance.
Please ensure you complete all the sections in the employer’s
statement before returning to QSuper promptly.
This will assist QSuper to progress the assessment of your
employee’s claim for an income protection benefit.
If your employee’s situation changes, it is important you let us
know straight away. This includes changing the type of leave they
take, if they start working again, or their employment is terminated.
Please call us on 1300 360 750 or email us at
insuranceclaims@qsuper.qld.gov.au to let us know.
5 Employer information
Where to send the completed form?
Name of employer Once you have completed this form you can:
Email us at insuranceclaims@qsuper.qld.gov.au
Full name of authorised officer
Position held
Phone number
Email address (not generic email address)
Date completed (dd/mm/yyyy)
Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Postal address GPO Box 200 Brisbane Qld 4001 ABN 60 905 115 063
Telephone 1300 360 750 (+617 3239 1004 if overseas) Fax 1300 242 070 SFN 261041941
Monday to Thursday 8:30am to 5:00pm AEST Website qsuper.qld.gov.au CNC-1135 01/18 IB29
Friday 9:00am to 5:00pm AEST
This form and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). We take the privacy of your personal information very
seriously. We’re collecting personal information from you so we are able to assess your claim and are authorised to do this under the Superannuation (State Public Sector) Act 1990. We may also
collect information from your employer, government agencies, other superannuation funds, anyone you authorise and if it is required or authorised by law. We may disclose your information to
your employer, authorised service providers (including QInsure Limited ABN 79 607 345 853 AFSL 483057 and any of its authorised service providers), other superannuation funds and government
agencies and to third parties if we need to, if you’ve given consent to the disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet
from our website or call us on 1300 360 750 and request a copy. The information outlined in this form is general information only and doesn’t take into account your personal objectives, financial
situation, or needs. Before you make any decision regarding a QSuper product you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy.
© QSuper Board 2018QSuper Form Please complete in block letters, in blue or black ink.
1
Income Protection Benefit Claim
(Part C) – Doctor’s Statement
Who needs to complete this form?
Your doctor needs to complete this part of the claim form. We need detailed information from them about your illness or injury before we can
pay you an income protection benefit. Remember you need to cover any costs your doctor charges to complete this form.
Also be sure to check out the Additional info about this form on page 5 to make sure you have all the info you need.
1 Claimant’s details (your patient)
Title Given names If yes, please provide the contact details of the doctor they first saw
and the consultation date.
Name
Surname
Specialty
Date of birth (dd/mm/yyyy) Height (cm) Weight (kg)
Date of consultation (dd/mm/yyyy)
2 Treating medical practitioner (completing Who diagnosed the patient’s condition?
this form)
Based on your objective clinical findings, please confirm the
Name patient’s diagnosis.
Specialty Practice Please describe your objective findings that support the
diagnosis (for example, if the diagnosis relates to a mental
illness, please provide criteria as per DSMIV)
Phone number
Email address
Postal address
If the diagnosis relates to a musculoskeletal condition, please
provide any details on ROM, strength testing, neurological
testing and any other special tests.
State Postcode
Are you this patient’s usual general practitioner?
Yes No
If yes, what date did you first begin treating this patient?
(dd/mm/yyyy) If the diagnosis relates to a cardiac condition, please indicate the
patient’s cardiac functional capacity:
Did this patient see any other doctors before they first consulted Class 1 – No limitations
you?
Class 2 – Slight limitations
Yes No
Class 3 – Marked limitations
Class 4 – Severe limitations
If your objective findings have changed since the initial
diagnosis, please tell us any updated findings.2
Income Protection Benefit Claim (Part C) – Doctor’s Statement
3 Medical History 4 Treatment and progress of the illness
or injury
Please outline the patient’s initial symptoms relating to this What active treatment (such as physiotherapy, surgery, counselling,
condition. medication) has the patient received from you and other practitioners
since their illness or injury was diagnosed?
Nature of treatment
Date referred
When did the patient’s symptoms for this condition first start or
occur? (dd/mm/yyyy)
Frequency of treatment
Have the patient’s symptoms changed in frequency or severity?
Effectiveness of treatment
Yes No
If yes, please describe how.
Medication
Dosage/frequency
Has the patient ever experienced these symptoms, or similar
symptoms, previously?
Yes No Date prescribed
If yes, from when? (dd/mm/yyyy)
Effectiveness of medication
If yes, please provide details.
Is there any additional treatment that would help improve the
patient’s functional capacity that they mightn’t be able to access due
to a lack of financial resources or other reasons?
Yes No
If yes, please provide details.
What tests or investigations have been done to date and what
were the results of these tests?
Please attach copies of test results where applicable (e.g. MRI, CT
scan, x-ray, ultrasound, blood/urine tests, ECG)3
Income Protection Benefit Claim (Part C) – Doctor’s Statement
5 Your patient’s capacity to work
How often are you seeing the patient at this time? When is their next What is your understanding of the patient’s occupation and their
appointment? duties?
Has your patient been referred to any consultants or specialists? Is the patient currently working?
Yes No Yes, part-time Yes, full-time No
If yes, please provide the consultant/specialist’s contact details. If yes, how many hours are they working per week?
Name
If no, how do the symptoms of their illness or injury stop them from
working?
Practice
Postal address
From what date was your patient unable to work due to the injury or
illness? (dd/mm/yyyy)
State Postcode
Phone number Please outline any specific medically supported restrictions and/or
limitations that would need to be considered to help the patient return
to work.
Date of first appointment (dd/mm/yyyy) Restriction and/or limitation 1
Functional capacity impacted e.g. lifting, sitting
Do you believe the patient has reached maximum medical
improvement (MMI)?
Yes No Restriction and/or limitation
If yes, please explain below.
Are these considered permanent?
Temporary Permanent
If temporary, what’s the expected timeframe of the restrictions and/or
limitations?
Current capacity e.g. 30kg, 30 minutes
Restriction and/or limitation 2
Functional capacity impacted e.g. lifting, sitting
Restriction and/or limitation
Are these considered permanent?
Temporary Permanent
If temporary, what’s the expected timeframe of the restrictions and/or
limitations?
Current capacity e.g. 30kg, 30 minutes4
Income Protection Benefit Claim (Part C) – Doctor’s Statement
Restriction and/or limitation 3 Restriction and/or limitation 5
Functional capacity impacted e.g. lifting, sitting Functional capacity impacted e.g. lifting, sitting
Restriction and/or limitation Restriction and/or limitation
Are these considered permanent? Are these considered permanent?
Temporary Permanent Temporary Permanent
If temporary, what’s the expected timeframe of the restrictions and/or If temporary, what’s the expected timeframe of the restrictions and/or
limitations? limitations?
Current capacity e.g. 30kg, 30 minutes Current capacity e.g. 30kg, 30 minutes
Restriction and/or limitation 4 Are there any specific or temporary workplace changes that could
help the patient return to work? Please outline below.
Functional capacity impacted e.g. lifting, sitting
Restriction and/or limitation
Are there any medical barriers to the patient returning to work within
Are these considered permanent? the restrictions/limitations outlined above?
Temporary Permanent Yes No
If temporary, what’s the expected timeframe of the restrictions and/or If yes, please provide details below.
limitations?
If the patient isn’t responding to treatment or there are delays
Current capacity e.g. 30kg, 30 minutes in accessing treatment, would you appreciate input from an
independent medical specialist?
Yes No5
Income Protection Benefit Claim (Part C) – Doctor’s Statement
6 Declaration
The information I’ve provided in this form is true and correct at the
time of completion.
Name
Signature
Date (dd/mm/yyyy)
Additional info about this form
Make sure you complete your section of the claim form in full so
the patient’s claim isn’t delayed.
If you’d like to know more about our privacy policy,
download QSuper’s Your Privacy factsheet on our website at
qsuper.qld.gov.au
Where do I send the form?
Once you’ve completed the form and attached any
necessary documents, send it to us at QSuper, Insurance
Operations, GPO Box 200, Brisbane Qld 4001.
Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Postal address GPO Box 200 Brisbane Qld 4001 ABN 60 905 115 063
Telephone 1300 360 750 (+617 3239 1004 if overseas) Fax 1300 242 070 SFN 261041941
Monday to Thursday 8:30am to 5:00pm AEST Website qsuper.qld.gov.au CNC-1135 01/18 IB29
Friday 9:00am to 5:00pm AEST
This form and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). We take the privacy of your personal information very
seriously. We’re collecting personal information from you so we are able to assess your claim and are authorised to do this under the Superannuation (State Public Sector) Act 1990. We may also
collect information from your employer, government agencies, other superannuation funds, anyone you authorise and if it is required or authorised by law. We may disclose your information to
your employer, authorised service providers (including QInsure Limited ABN 79 607 345 853 AFSL 483057 and any of its authorised service providers), other superannuation funds and government
agencies and to third parties if we need to, if you’ve given consent to the disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet
from our website or call us on 1300 360 750 and request a copy. The information outlined in this form is general information only and doesn’t take into account your personal objectives, financial
situation, or needs. Before you make any decision regarding a QSuper product you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy.
© QSuper Board 2018Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Postal address GPO Box 200 Brisbane Qld 4001 ABN: 60 905 115 063
Telephone 1300 360 750 (+617 3239 1004 if overseas) Fax 1300 242 070 SFN: 2610 419 41
Monday to Thursday 8:30am to 5:00pm AEST Website qsuper.qld.gov.au CNC-1135 01/18 IB29
Friday 9:00am to 5:00pm AEST
This guide and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). The information provided is general information only and
doesn’t take into account your personal objectives, financial situation, or needs. You should consider whether the product is appropriate for you by reading the product disclosure statement (PDS) and
consider seeking financial advice before making a decision. You can get a copy of the PDS by downloading a copy from our website at qsuper.qld.gov.au or call us on 1300 360 750. © QSuper Board 2018You can also read
