(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. The following must be included when submitting this form: Original/Certified copy of the retrenchment letter from the employer with supporting documents Certified copy of ID document of life insured Proof of bank account details of claimant (e.g. cancelled cheque or bank account statement) Three months’ payslips Employer’s Section 189 documents Return the completed form and the above documents to lifeclaims@hollard.co.za or fax to 086 659 0135.
Life Assured details
Policy no.
Full name
ID no.
Cell no.
Tel. no.	Fax no.
Residential address
Postal address
Retrenchment details
Date of retrenchment	D D M M Y Y Y Y
Employer name
Employer address
Employer contact details
Declaration by claimant
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.
Signature	Date	D D M M Y Y Y Y