(To be completed by claimant)
Your claim will only be considered if every question has been completed in full. To ensure the continuance of your payments, we require you to sign this form in the presence of one of the persons set out below. Note that Hollard Life does not deduct tax from any income disability benefit payments as of 1 March 2015. 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
Claimant details
Full name
ID no.
Cell no.
Tel. no.	Fax no.
E-mail address	Mandatory
Residential address
Postal address
Relationship between claimant and life insured: (e.g. father/son)
Declaration
I certify that the above named has confirmed that he/she is entitled to this benefit and has signed this form in my presence. To be signed/dated and stamped by one of the following Commissioners of Oaths.
Magistrate	Consultant
Commissioner of oaths	Bank official
Address	Clergyman
Official stamp date	Official stamp
Signature (claimant)	Date	D D M M Y Y Y Y
Signature (witness)	Date	D D M M Y Y Y Y
Important notice: Anyone that receives payment to which they are not entitled could be liable for prosecution.