(To be completed by life assured)
If you are only claiming for business overhead expenses, the disability forms for medical attendant and claimant need to be completed as well. Your claim will only be considered if every question has been completed in full. The following must be included when submitting this form: Proof of all expenses detailed below Audited financial statements Proof of the business bank account details Return the completed form and the above documents to lifeclaims@hollard.co.za or fax to 086 659 0135.
Life assured details
Policy no.	ID no.
Full name
Tel. no.	Cell no.
E-mail address	Mandatory
Business details
Name of company
Business tel. no.	Fax no.
Business address
Postal address
What is the exact nature of the business?
How long has the company been in business?
State share/interest in business
Statement of expenses for the period being claimed for
Description	Number	Total monthly payroll
Administration
Secretarial
Artisans
Assistants
Other
TOTAL	R
Employee details:
Description	Expense
Mortgage/rent/lease
Water
Electricity
Telephone
Maintenance and janitorial services
Property and liability insurance premium(s)
Other (specify)
TOTAL	R

Accounting details

Full name(s) of accountant/auditor
Under which company name does he/she trade?
Tel. no.	Fax no.
E-mail address	Mandatory
Business address
Postal address
Declaration by life assured
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 policy owner in all other circumstances. I declare 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