2018 NSW JRL Sports Injury Claim Form

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NSW Junior Rugby League Sports Injury Claim Form

This information must be completed and signed by the Injured Person, a Club Official and your District Administrator and forwarded to Fullerton.

Health Corporate Services within 30 days of injury. DO NOT wait for all accounts / receipts.

We may be unable to deal with your claim properly if you have not answered all questions fully.

IMPORTANT INFORMATION: PLEASE READ
IMPORTANT NOTE REGARDING CLAIMS FOR MEDICAL EXPENSES
We do not provide cover for any account that is fully or partially covered by Medicare. This means we do not cover expenses claimable from Medicare or the Medicare Gap.

The reason for this is we’re not permitted by law to do so. Please do not send us any account/receipt that is covered by Medicare or Medicare statements.

Do not wait for any account / receipt before sending.

We do cover Non Medicare medical expenses. We will pay the percentage amount shown in the policy schedule of charges for Private Hospital, Dental, Ambulance, Chiropractic treatment, Physiotherapy, or any similar provider of medical services provided always that such treatment is certified necessary by a legally qualified medical practitioner.

HOW TO CLAIM MEDICAL EXPENSES ONLY
When claiming for Non Medicare expenses you must have the ‘Sports Injury Report Form’ fully completed.

Medical treatment must be certified necessary by a legally qualified medical practitioner. This could be your treating doctor or dentist. The Attending Physician’s Statement must be fully completed (without expense to the insurer) prior to submitting a claim.

Please note that medical cover is limited for 12 months from the date of accident.

For each and every claim a $100.00 excess will apply ($50 if you are in a private Health Fund and $25 for ambulance only claims).

Please check with your club for exact cover.

HOW TO CLAIM LOSS OF INCOME
When claiming for Loss of Income you must have the ‘Sports Injury Report Form’ fully completed including the section to be completed by your Employer. If self employed you will need to attach proof of earnings such as a tax return.

The policy has a 14 day elimination period (excess) this means the first 2 weeks off work will not be reimbursed.

You must have your treating doctor complete the Attending Physician’s Statement (without expense to the insurer) prior to submitting a claim.

If your disability is continuing, please forward medical certificates every two weeks. Loss of income benefits will not be paid until all statements and documents are submitted.

PLEASE REMEMBER
1. If you have Private Health Insurance, you must submit details to your insurer prior to claiming from us.
2. Attach evidence of receipts / accounts for the treatment you are claiming.
3. Excesses and percentages of cover apply under the policy.

It is suggested that you check these details with your Club/Association representative prior to submitting a claim to us.

OPEN ATTACHMENT FOR FULL INFORMATION




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