Emergency Transport Cover App

Instructions for completing an Emergency Transport Claim

This form is to be fully completed (to avoid any processing delays) and submitted with the following documents:

Tax Invoice/s from the Emergency Transport Service provider

If the claim is for a Dependant (full-time, fully dependant student up to 25 years of age), a copy of a Student Enrolment Document issue by a Secondary or Tertiary Institution to verify full-time student status

ETU members should read the Emergency Transport Benefit Scheme Rules prior to submitting an Emergency Transport Claim with the ETU.

Member Details

ETU Membership Number*

Occupation*

Name

Address*

Home Phone*

Mobile Phone*

Email Address*

Date of Birth*

Marital Status*

Married
Separated/Divorced
De Facto Partnered
Single

Employer/Company Name*

Employer/Company Address*

Emergency Transport User's Details

Emergency Transport used by

Member
Spouse
De Facto Partner
Dependent Child

Emergency Transport User's Date of Birth*

Third Party Liability Details

Please ensure that all the below has been checked and answered before submitting your Emergency Transport Claim to the ETU.

Do you have Private Health Insurance that covers you and your Dependants for Ambulance Services?*

Yes
No

If you answered YES, please refer your Ambulance Invoice to your Private Health Insurance provider.

If the person/s using the Emergency Transport is covered by a Victoria issued DSS Pensioner Concession, Health Care, Veterans Affairs, or specific Entitlement Card, the Ambulance Invoice should be referred to the organisation that has issued the card.
If the Emergency Transport was required for a workplace incident/accident, the Ambulance Invoice should be referred to your Employer if you have lodged a Workcover claim.
If the Emergency Transport was required for a registered motor vehicle accident, please refer the Ambulance Invoice to the Transport Accident Commission (TAC).
If the Emergency Transport was required for a sporting accident, please refer the Ambulance Invoice to your club’s insurance provider.

Medical reason for using the emergency transport*

Upload your ambulance invoice*

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 100 MB.

Upload your dependant's student enrolment document (if relevant)

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 100 MB.

If your claim is for a dependant (full-time, fully dependant student up to 25 years of age) you must upload a copy of a Student Enrolment Document issued by a secondary or tertiary institution to verify their full-time student status.

Declaration

Declaration*

I agree with the declaration

I/We declare that the information supplied on this form and in the attached documentation is correct and that I/We have not withheld any pertinent information that may affect this claim. I/We have read and understand the ETU’s Emergency Transport Benefits Scheme Rules. I/We release authority to the ETU to contact any of the above on my/our behalf for any payment or reimbursement of the Emergency transport claim.

Email

This field is for validation purposes and should be left unchanged.

Emergency Transport Cover App

Emergency Transport Benefits Scheme Claim Form – APP

Member Details

Emergency Transport User's Details

Third Party Liability Details

Declaration