Kids benefit (Sickness) – Tip Friendly Society

OVERVIEW

This form collects all information needed to process your sickness claim. Please complete every section accurately and provide all supporting documents required by TIP Friendly Society. Your Physician and Employer may also be required to complete their respective statements. Claims may be delayed if any section is incomplete or documents are missing.

MEMBER DETAILS

*Member Number

*TRN

Phone Number

*Full Name

*Email

*Alternate Phone Number

*Current Address

PHYSICIANS STATEMENT

The Physician’s Statement must be completed by the doctor who treated the member for the injury or illness. It provides TIP Friendly Society with the essential medical details required to assess the claim—diagnosis, treatment dates, level of disability, hospitalization information, prognosis, and confirmation of when the member can resume work. This form must be completed directly by the attending physician, signed, and stamped.

The Society requires this form as part of the mandatory Proof of Death documents for Kids Benefit claims.

Download the official Attending Physician/Surgeon Statement. This form must be printed and completed by the physician. TIP Friendly Society does not accept versions filled out by the member.

File Download

After the physician has fully completed, signed, and stamped the form, upload the scanned copy here to proceed with your claim.

*File Upload

X

ADDITIONAL DOCUMENTS REQUIRED

Valid Identification

X

Original Surgeon's Fee

X

ACH AUTHORIZATION - Please provide additional evidence of your banking details

*Name as it appears on your bank account:

I hereby authorize TIP Friendly Society to make direct deposit to my bank account as stated below:

*Name of Bank

*Amount:

*Branch

*Contact Number

*Account Number

*Account Type

Other Account Type

*Email Address

I acknowledge that if the information presented is erroneous, I will pay administrative fees of $1,000.00 to have the matter resolved and corrected.

Signature

Date

DECLARATIONS – COMPULSORY SECTION – REQUIRES COMPLETION

Privacy
TIP Friendly Society collects your personal information in order to calculate your loss and entitlements, determine our liability and handle claims. When handling your claim, we may have to disclose and obtain your personal and other information to and from third parties such as other insurers, reinsurers, loss adjusters, medical attendants, or other parties as required by law.

Authority
I authorise TIP Friendly Society to contact any Physician or medical attendant who has treated me or examined me or any person or
organisation that employs or has employed me or any other person or organisation who has or may have information regarding my
illness/injury for any information it may require to assist in the proof and settlement of my claim. A photocopy or faxed copy of this
authority can be acted upon as it was an original.

Declaration
I/we certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been
withheld.

I/we understand that this claim may be refused/denied if information is found to be untrue, inaccurate or concealed.

I/we acknowledge that I/we have read and understood the Privacy Section information and Authority referred to above and consent to the collection, storage and use and disclosure of my/our personal and sensitive information. I/we acknowledge that if I/we do not agree to the collection of this personal information, then TIP Friendly Society shall not be held liable for any settlement of claim

*Name of Claimant

Signature of the Claimant

Date

Signature of the Insured (If other than Claimant)

Date