Your claim will only be considered if every question has been completed in full. The following must be included when submitting this form: An original/certified copy of the printed Home Affairs death certificate (no unabridged death certificates will be accepted) Certified copies of the ID documents of both the deceased and the claimant Proof of the banking details of the claimant (e.g. cancelled cheque or bank statement) A fully completed Hollard Life Death Claim Form by the police in the case of accidental death 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.
Name of insured
Tel. no.	Cell no.
E-mail address	Mandatory
Residential address
Postal address
Details of deceased
Full name
ID no.
Relationship between claimant and deceased (e.g. father/son)
Name of employer prior to death
Occupation prior to death
Claimant details
Full name
ID no.
Cell no.
Tel. no.	Fax no.
E-mail address	Mandatory
Residential address
Postal address
Details of the death
Date of death	D D M M Y Y Y Y
Name, address and contact number of hospital/place of death
Provide full details of the cause of death (‘natural causes’ or ‘unnatural death’ is not acceptable – state the circumstances leading to death)
Date of funeral	D D M M Y Y Y Y
Cemetery place of burial

Name, address and contact number of funeral parlour that directed the burial
Name of police station where death was reported
Police case number (where applicable, e.g. unnatural causes)
Name of the investigating officer and contact number
Name, address and contact number of medical attendant who certified the death
Declaration by claimant
I declare that the statements above are true and complete. In the event that this claim or any supporting documentation is found to be fraudulent, Hollard Life reserves the right to proceed with the appropriate action against me. I further authorise any medical attendant 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, to disclose this information to Hollard Life.
Signature	Date	D D M M Y Y Y Y