(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. NB: It is important that this form is completed with details that are accurate, true and in full and that you sign the form, as it constitutes a legal document. 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.
Home tel. no.	Fax no.
E-mail address	Mandatory
Physical address
Postal address
Relationship between claimant and life insured: (e.g. father/son)
Details regarding any income earned
Have you participated in any form of work for remuneration since Hollard Life started paying your benefit?	Yes	No
If yes, supply details below
Type of work	From when	To when	Amount paid	How has your illness/injury made it difficult for you to do this work?
Have you received payment from any of the following sources?
Yes/No	Amount received	Lump sum or monthly payment?	Payment made from (date)	Payment made to (date)
Workmen’s compensation (WCA/COID)
Unemployment Insurance Fund (UIF)
Third party claim
Any other insurance benefit
Commission
Other (please specify)
Declaration by claimant
I declare that 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