How to Complete the Teachers Health Accident & Injury Claim Questionnaire: Complete Guide

When an injury or accident occurs, navigating insurance claims can be complex—especially when other compensation sources might be involved. This guide explains how to properly complete the THF-A&I – 11/15 Accident/Injury Compensable Claim Questionnaire, a mandatory form for Teachers Health members claiming benefits for injury-related treatment.

Download the Form: Teachers Health Accident & Injury Claim Questionnaire (PDF)

Before You Start: Understanding the Form’s Purpose

Why This Form Exists

This is not a standard claim form. It is a mandatory questionnaire that Teachers Health uses to determine if your injury or condition is potentially compensable through another source. According to Teachers Health Fund Rules, the fund is not required to pay benefits where there is an entitlement to compensation or damages from another source.

Completing this form truthfully is legally required. Your claim will be placed on hold until this completed form is returned.

Key Question: Is Your Injury/Accident Compensable?

Answer this first to know how to proceed:

Scenario A: Purely Private Accident (e.g., fell at home, sports injury with no third party).
- Path: Complete Questions 1-4. For remaining questions, write “N/A” (Not Applicable).
- Goal: Confirm no other compensation source exists.
Scenario B: Potentially Compensable Incident (e.g., car accident, workplace injury, public liability incident).
- Path: You must answer every question in detail.
- Goal: Provide all information about other potential claims (CTP, Workers’ Compensation, etc.).

Document Checklist

Gather this information before filling out the form:

Your Teachers Health member number.
Patient’s full name and date of birth.
Exact date, time, and location of the incident.
Detailed description of how the injury happened.
If applicable: Third-Party/CTP insurance details, Workers’ Compensation claim number, solicitor’s contact information, or any letters denying liability from other insurers.

Section-by-Section Filling Instructions

Complete the form in blue or black pen. Do not leave any question blank. Use “N/A” where instructed.

Top Section & Question 1: Basic Identification

Date: Today’s date (DD/MM/YYYY).
Member No.: Your Teachers Health membership number.
Member Name: The primary policy holder’s name.
Patient’s Name: The injured person’s full name (if different from member).
Treatment by: Name of the main treating doctor/hospital.
From: The date treatment began (DD/MM/YYYY).

Question 2-4: Incident Details

Q2. Date & Time of Accident: Provide the precise date and time (AM/PM).
Q3. Place of Accident: Be specific (e.g., “Kitchen at 123 Home St, Sydney,” “Main St & Park Rd intersection”).
Q4. How it Happened: Provide a clear, factual narrative.
- ⚠️ Special Note for Hernia: If claiming for a hernia repair not caused by a specific accident, you must provide the date of onset of symptoms here.

Question 5: Motor Vehicle Involvement

Did it involve a motor vehicle? (Yes/No).
If YES, you must complete all sub-questions:
- State if patient was driver, passenger, or pedestrian.
- Declare any entitlement to claim from a Third-Party/CTP insurer.
- If entitled: Provide the vehicle owner’s name/address, insurance company details, and claim number.
- If not entitled: You must state the reasons why.
- Critical Requirement: If a claim has been denied, you must attach a copy of the denial letter.

Question 6: Workplace Connection

Did it happen at or due to work? (Yes/No).
Patient’s Employment Status: Select one.
If employed/self-employed: Provide the employer’s/business name and address.
Entitlement to Workers’ Compensation? (Yes/No).
If NO, you must state the reasons.
Critical Requirement: If a Workers’ Comp claim has been denied, you must attach a copy of the denial advice.

Question 7 & 8: Other Recovery Actions & Legal Representation

Q7: Are you taking (or entitled to take) action to recover costs from any other source? (e.g., travel insurance, public liability). Answer Yes/No.
Q8. If you answered YES to Q5, Q6, or Q7: You must provide the full contact details of any solicitor or agent acting on your behalf.

The Legal Declaration: Understanding Your Obligations

This is the most important part of the form. By signing, you agree to several key conditions:

Authorization: You allow Teachers Health to contact any person, organisation, or health provider related to the incident.
Obligation to Pursue Other Claims: If another source (CTP, Workers’ Comp) is potentially liable, you must pursue that claim “promptly and diligently.”
Duty to Inform & Repay:
- You must update Teachers Health on the status of any external claim.
- You must inform them of any settlement.
- You must include the costs Teachers Health paid in your external claim.
- You must promptly repay any benefits Teachers Health paid if your external claim is successful.

Signatures Required:

Signature of Patient/Member: The person completing the form must sign, print name, and date.
Witness Signature: A witness must sign, print their name, and date. This cannot be the same person as the claimant.

🚫 Severe Consequence Warning: Providing false or incomplete information on this form can result in claim denial, recovery of paid benefits, and potential policy implications.

Submission Process

Once fully completed and witnessed:

Send the completed original form (and any attached denial letters) to:
Teachers Health Fund GPO Box 9812 Sydney, NSW, 2001

Submission Tips:

Make a photocopy of the entire submitted package for your records.
Consider sending via registered post for tracking.
Do not email this form unless specifically instructed by Teachers Health, as it contains sensitive personal and legal information.

After Submission: What Happens Next?

Claim Status: Your related hospital or Extras claim will remain on hold until this questionnaire is received and assessed.
Assessment: Teachers Health will review your answers to determine if another source is primarily liable for the costs.
Possible Outcomes:
- No Other Entitlement Found: Your Teachers Health claim will proceed for assessment under your standard cover.
- Other Entitlement Identified: You will be guided on the need to pursue the third-party claim first. Teachers Health may pay benefits conditionally, subject to you fulfilling the repayment obligations outlined in the declaration.
Communication: Teachers Health may contact you or your nominated solicitor for further clarification during their assessment.

Crucial Notes & Tips for Accurate Completion

Completing the Form:

Be Factual, Not Fault-Based: Describe how the injury happened, not who you think is at fault. (e.g., “Slipped on wet floor in supermarket” not “Supermarket was negligent”).
Consistency is Key: Ensure dates and details match those on any related medical claims or police reports.
“N/A” is Your Friend: If an entire question block does not apply, write “N/A” clearly in the first blank to indicate you have read it and it is not relevant.

Navigating Third-Party Claims:

Do Not Delay: If the incident involves a potential third-party claim (car accident, public place), you should initiate that process simultaneously with your health claim.
Keep Records: Maintain a dedicated file for all correspondence related to the injury: medical bills, insurance letters, police report numbers, and solicitor communications.
Transparency with Teachers Health: If your situation changes (e.g., you hire a solicitor after submitting this form), inform Teachers Health immediately.

Common Mistakes to Avoid:

Leaving Questions Blank: This will cause your form to be returned, delaying everything.
Forgetting Attachments: If a third party has denied liability, the denial letter must be attached.
Missing Witness Signature: The form is invalid without an independent witness.
Assuming Teachers Health is Primary: Always investigate other potential sources of compensation first.

Frequently Asked Questions (FAQ)

Q: Do I need to complete this form for every injury-related claim?
A: Yes. Any claim for treatment related to an accident or injury potentially caused by an external event requires this form. It’s a standard procedure to screen for compensable incidents.

Q: What if I don’t know all the insurance details for a car accident yet?
A: Provide as much as you know (other driver’s details, police report number). You can note “details pending” but must commit to providing them to Teachers Health as soon as you have them, as per the declaration.

Q: I was injured at work but my employer says it’s not a Workers’ Compensation matter. What do I do?
A: You should still answer “Yes” to Q6 and in the “reasons” section state “Employer disputes liability.” You may need to seek independent advice about your Workers’ Compensation rights. Teachers Health will need to understand this dispute.

Q: How does this affect my no-claim bonus or premiums?
A: This is a procedural form to determine benefit liability. A claim assessed under this process, if paid by Teachers Health, is typically considered a standard claim and may affect your no-claim bonus as per your product’s terms.

Q: Who can witness my signature?
A: Any independent adult (18+), such as a friend, neighbour, or colleague, who is not named in the claim. They do not need to understand the content, only witness you signing.

Need Help? For questions about the form or your cover in relation to an injury, contact Teachers Health via their official support channels.

By understanding the purpose of this form, gathering the correct information, and completing it with thorough, honest detail, you facilitate a faster assessment of your injury-related claim and ensure compliance with your fund rules.

Customer Care Phone Number