Wiggle Personal Accident
(If you have it handy)
Date of birth
Preferred method of contact
Serial number of bicycle/s under claim:
Date of occurrence:
Time of occurrence:
Where did this incident occur?
Please describe what happened:
Injuries sustained in the accident
Please provide details:
Insurance and medical history
Do you have private health insurance?
If yes, please provide details:
Name of fund:
Have you had the same or similar injury before?
If yes, please provide details of this injury:
Witness contact number:
Have you ever made a personal accident claim?
if yes, please provide details of this:
Details of non-Medicare expenses
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 that we do not cover expenses claimable from Medicare, nor do we pay the Medicare gap. The reason for this is that the Australian Health Insurance Act does not permit us to do so. Please do not send us any account or receipt for a service that is covered by Medicare. We do cover non-Medicare medical expenses for charges involving 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.
Upload copy of invoices
Please provide copies of all invoices for medical treatment received that you are claiming for:
Health fund rebate
Did you receive a health fund rebate for any of the invoices you are claiming for:
If yes, please state amount received:
*I hereby certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim
has been withheld. I understand that this claim may be refused if information is untrue, inaccurate or concealed.
*I authorise Wiggle or its agents to give to, or obtain from, other insurers or any insurance reference bureau, any information to this claim
or any other claim made by me or any insurance held by me.
*I authorise any hospital, physician or other person who attended me to provide Wiggle or its agents with copies of all hospital and medical records together with any or all information with respect to any injury, medical history, consultation, prescription or treatment. A photocopy or faxed copy of this authority can be acted upon as if it were an original.
Send me a copy of my responses
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