Claim Form with Example (For Viewing Purposes Only)
Example to be used for claims which occurred after the 1st Sept 2018
Blank Claim Form
To be used for claims which occurred after the 1st Sept 2020
To be used for claims which occurred after the 1st Sept 2018
To be used for claims which occurred after the 1st Sept 2017
To be used for claims which occurred before the 1st Sept 2017
Useful Tips when completing Claim Form
Section 1 – School Details
Certificate Number – this can be obtained from the school.
Section 2 – Name of Injured Pupil or Staff member
Must be completed to allow us to make contact with Parents/ Claimant. A Parent’s contact number or email address can be put in this section to enable us respond quicker.
Section 3 – Details of the Accident
Question A – Date of accident must be ALWAYS completed. A separate claim form is required for each accident;
Question B – Please advise the location of the accident (i.e. home, swimming pool, school etc.) and explain what exactly the child was doing (i.e. fell of the couch and sustained a bang to the forehead, banged a toe while swimming, running in the yard and tripped over etc.);
Question C – Describe fully the extent of the injury and the exact part of the body which was injured e.g. left arm, right leg etc. For dental accidents please advise which tooth/ teeth suffered the trauma;
Question F – The School Personal Accident Scheme covers medical/ dental expenses incurred as a result of an accident which are not recoverable from any other source. A claim must be pursued through your Private Medical Insurance first and thereafter Pupil Cover will cover any shortfall that is not recovered;
If you have Private Health Insurance please insert the Insurers name (i.e. VHI, LAYA etc.)
Question G – If a child was playing for a Club at the time of the accident then a claim must firstly be pursued through the Club’s insurance and Pupil Cover will cover any shortfalls that is not recovered;
Question H – Please note you must pursue a claim through your Private Medical Insurance or Clubs Insurance first. Once cover is exhausted Pupil Cover will cover any shortfall.
Question I – If expenses are not covered by the Private Medical Insurance or Club’s Insurance please advise the reason why not. If expenses are partly covered, Pupil Cover will require a balancing statement / letter showing the recovered amount;
Question J – Please note only Medical Expenses incurred solely as a result of an accident can be claimed for. The scheme does not cover travel or additional expenses such as accommodation, loss of earnings, parking etc;
Question L – If the treatment is ongoing please advise what further treatment/ cost involved in such treatment may be required and the anticipated completion date.
An interim payment can be made for expenses incurred to date. If no further treatment is expected within 12 months the claim will be closed. The claim can be re-opened at any time provided the treatment is solely relating to the initial accident.
Section 4 – Applicable for Dental Injuries Only
If claiming for dental injuries please advise (1) Which tooth / teeth are involved in trauma (2) what further treatment may be required (3) the estimated cost and (4) time frame.
Section 5 – Declaration/ Discharge
This section must ALWAYS be signed by the Parent/ Guardian. If an accident occurs during school activities (in the school or away from school premises i.e. school match or trip) the form must also be signed by the school’s Principal/ staff member.
Section 6 – Payee Declaration
This must be completed if the payee is someone other than the Parent/ Guardian.
Section 7 – Notes
Question 2 – ORIGINAL itemised Receipts/ Invoices must include:-
• What treatment was carried out;
• The date the treatment took place;
• Which part of the body was treated;
• The cost of each treatment;
• In the case of dental, which tooth / teeth suffered trauma.
NOTE: Any treatment for pre-existing conditions or conditions not solely related to the accident may not be covered by the Scheme
Brennan Educare reserves the right to request confirmation from Consultant/ Doctor/ Dentist/ Physiotherapist that treatment received was required solely as a result of the accident and not as a result of any pre-existing condition present prior to the accident or conditions not related to the accident.
Question 3 – The Medical Certificate MUST be completed by a Medical Practitioner if the estimated claim may exceed €1,000.
Section 9 – Receipts/ Invoices
Please complete this section to ensure no medical evidence is omitted from your claim.
NB. Until confirmation of cover is provided, costs associated with treatments are the sole responsibility of the parent or guardian