(To be completed by the medical attendant)
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 following copies must be included when submitting this form along with any other pertinent information to this claim: Diagnosis (e.g. cancer: histology; heart attack: blood enzymes, R & E ECG; stroke: MRI scans; cardiac surgery: angiogram, angiography reports) Specialist reports All investigations 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.
Name of insured
Occupation	Date of birth
Postal address
Diagnosis of dread disease relevant to this claim
The cause of the patient’s dread disease
Date of diagnosis	D D M M Y Y Y Y
Was the patient informed of the diagnosis?	Yes	No If so, when?	D D M M Y Y Y Y
When did the patient experience the earliest symptoms?	D D M M Y Y Y Y
Details of complications or concurrent conditions
a. Date of first consultation	D D M M Y Y Y Y
b. Date of last consultation	D D M M Y Y Y Y
c. Date on which treatment commenced?	D D M M Y Y Y Y
Names, addresses and contact numbers of any other medical practitioners who may be or have been consulted

Details of any hospitalisations or special investigations
Details of any treatments conducted or anticipated
Progress thus far and anticipated prognosis
Please provide any other information that may be useful to the company in assessing this claim
Declaration by medical attendant
I declare that I have personally attended to the patient and that this form has been completed to the best of my knowledge.
Full name
Qualifications	Practice no.
Work tel. no.	Cell no.
E-mail address	Mandatory
Postal address
Signature	Date	D D M M Y Y Y Y