(To be completed by claimant)
Please note that it is essential to complete this form in full to prevent unnecessary delays as a result of missing information. Where there is more than one beneficiary or policy owner, each claimant needs to complete and submit this form. The following must be included when submitting this form: A certified copy of the death certificate A certified copy of the deceased’s identity document A certified copy of the claimant’s identity document For unnatural death, we require the Hollard Life Death Claim form by the police to be fully completed by the investigating officer A certified copy of the letter of executorship in the event of no beneficiary nomination Proof of bank account details of the claimant (e.g. copy of original bank statement or cancelled cheque) Death Claim Form by medical attendant, to be completed by the deceased’s usual medical attendant Return the completed form and the above documents to lifeclaims@hollard.co.za or fax to 086 659 0135.
Policy owner details
Policy no.	ID no.
Full name
Complete the following if the deceased had any other life insurance
Company name	Commencement date	Sum assured
R
R
R
Life assured’s details
Full name
ID no.
Postal address
Was the life assured insolvent or under debt administration?	Yes	No
Occupation
Date of birth	D D M M Y Y Y Y	Date of death	D D M M Y Y Y Y
Place of birth	Duration of illness if natural causes
Provide full details of the cause of death (‘natural causes’ or ‘unnatural death’ is not sufficient – state the circumstances leading to death)
Details of doctor (usual medical attendant)
Name and surname	Tel. no.
Name, address and telephone number of each doctor that attended to or prescribed anything for the deceased during the five years preceding death
Name, address and telephone number of the doctor who certified death
Undertaker’s details
Name and surname
Tel. no.
Claimant’s details
Full name
ID no.
Cell no.
Tel. no.	Fax no.
E-mail address
Postal address
Residential address
Have you been insolvent, or has any assignment to creditors been made since the inception of the policy?	Yes	No
If yes, give full details
In what capacity, or by what title, do you claim the amount due under the policy?
(If executor, administrator or guardian, a certified copy of the appointment must be included when submitting this form.)
Declaration by claimant
I am entitled to make a claim on this policy and accept that the proceeds arising from this claim will be payable to the cessionary on Hollard Life records if the policy has been ceded, otherwise to the nominated beneficiaries if the policy owner is deceased, or to the estate of the deceased policy owner if no beneficiaries have been nominated, or to the policy owner in all other circumstances. I declare that the above details are true and complete. I authorise any doctor or any other person who has attended to the life insured, or any hospital or other institution that has medical information about the life insured or claimant, to disclose such information to Hollard Life.
Full name
Signature	Date	D D M M Y Y Y Y