(To be completed by police)
Please note that should there be any charges for the completion of this form, such charges will be for the life insured’s account. The claim will only be considered if every question has been completed in full by the investigating officer at the police station where the death of the deceased was reported. Return this completed form and the copies to lifeclaims@hollard.co.za or fax to 086 659 0135.
Life assured details
Policy no.	ID no.
Name of insured
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 death	Time of death
Cause of death
Magisterial district
Police station where incident was reported
Case no.	Date reported	D D M M Y Y Y Y
Name of investigating officer
Was the deceased involved in a motor accident?	Yes	No
If yes, was the deceased a driver, passenger or pedestrian?
If yes, was a blood alcohol test done on the deceased?	Yes	No
If yes, results of blood alcohol test?
Was the deceased involved in an assault?	Yes	No
If yes, was the deceased an innocent bystander?	Yes	No
Is suicide suspected?	Yes	No
Is there any suspicion or probability of family involvement in the death of the deceased	Yes	No
Has an inquest been held or will one be held?	Yes	No
If yes, name of court
If yes, date of inquest held/to be held	D D M M Y Y Y Y
If yes, inquest number and reference
Was a post-mortem done?	Yes	No
Have/will criminal proceedings been/be instituted?	Yes	No
If yes, name the person charged
What were/are the charges?
If judgement has been given, what was the verdict?
Which court?
Date of trial	D D M M Y Y Y Y
Trial and reference no
Give a short description of the circumstances of the death
Declaration by police
I declare that the statements above are true and complete.
Full name
Rank
Station	Official stamp
Tel. no.
Signature
Date	D D M M Y Y Y Y