(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. The following must be included when submitting this form: Proof of full income will be required for continuation of payment if the claim lasts longer than 3 months Return the completed form and the above documents to lifeclaims@hollard.co.za or fax to 086 659 0135.
Claimant details
Policy no.	ID no.
Name of claimant
Date of birth	Work tel. no.
Home tel. no.	Cell no.
E-mail address	Mandatory
Physical address
Postal address
Tax no.	Tax office
Employers name
What is the reason for the claim?
Details of current employment
When did you start working for your current employer?	D D M M Y Y Y Y
Were you working full-time for the above employer?	Yes	No
What is your current position?
When did you start in your current position?	D D M M Y Y Y Y
Provide a detailed description of your duties
Provide a summary of your duties
Does your work require any of the following (tick yes for all the functions that are applicable to your job and indicate the percentage of time allocated to these tasks) (must add up to a total of 100%)
Function	Yes	% time	Function	Yes	% time	Function	Yes	% time
Prolonged travelling	Prolonged sitting	Prolonged standing
Regular bending	Climbing stairs	Computing
Heights	Carrying heavy objects	Machine repair (office)
Large machine repair (industrial machinery and motors)	Heavy manual labour (digging, loading)	Light manual labour (physically packing, factory working, sorting)

Indicate which best describes your working conditions and where applicable provide details
Work conditions	Yes	Details	Work conditions	Yes	Details
Indoor	Outdoor
Vibration	Noise
Height	Depth
Humid/cold temp	Wet
Rough terrain	Smooth terrain
Underground	Fumes
Balance required	Dry
Dust	Other
Any other condition to be considered
When were you last able to perform fully in your current position?	D D M M Y Y Y Y
When did you stop working?	D D M M Y Y Y Y
Apart from your current position, supply a history of previous positions held with your current and previous employers
Date	Details of employment
From	To	Company	Position held	Type of work done (e.g. welding)	Reason for change
Have you been able to perform any part of your main duties or another job since you were unable to do your job in full? If yes, give details, including dates, job description and remuneration
What was the highest level of education that you achieved?
Give details of formal training, qualifications and any courses that you have attended during your working career
Date	Name of employer, college or institution	Qualifications obtained	Brief description of course content
From	To
When do you expect to be able to resume work?
Part-time basis	D D M M Y Y Y Y	Full-time basis	D D M M Y Y Y Y
What was your total monthly income before you became disabled?	R
Are you still receiving a salary?	Yes	No	R
Full pay: From:	D D M M Y Y Y Y	to	D D M M Y Y Y Y
Amount	R
Reduced pay: From:	D D M M Y Y Y Y	to	D D M M Y Y Y Y
Amount	R

Give details of any benefit salary or remuneration that you have received or expect to receive as a result of your disability or during your disability, including details of salary, benefits from an insurance company, pension fund, state fund or any other source
Source of benefit (state name of company and you reference no.)	Type of benefit (e.g. insurance, lump sum)	Amount
Have you resided outside South Africa in the past year?	Yes	No
If yes, provide details in the table below
Date	Country	Reason
From	To
Details of disability
What do you understand to be wrong with you? Give details in own words, refer to reports, is not acceptable.
When did you first experience symptoms relating to this disability?	D D M M Y Y Y Y
Describe these symptoms
Has any of the following contributed in any way to your disablement?
Function	Yes	No	Details
Previous illness or injury
Hazardous pursuit or pastime
Habits, e.g. excessive alcohol consumption
Self-inflicted injuries
When did you first consult a medical practitioner in respect of your current disability?	D D M M Y Y Y Y
Provide details of the doctor
Practice no.
Tel. no.	Fax no.
Full name
Address
Have you ever suffered from any other form of disablement or been declared disabled from employment before?	Yes	No
Provide details
Details of your usual family doctor
Name
Address
Tel. no.	Fax no.

Details of the doctor who is attending to your disability
Name
Address
Tel. no.	Fax no.
Provide names, addresses and telephone numbers of all other medical practitioners including specialists consulted in connection with this disability
Name	Type of practice/speciality	Address	Telephone
Have you been referred to any health care professionals, e.g. physiotherapists, occupational therapists, psychologists, or other medical specialists?	Yes	No
If yes, provide details below
Name	Type of practice/ speciality	From	To	Treatment	Outcome
Have you had any test, x-rays or special investigations relating to your disability or any other impairment?	Yes	No
If yes, give details
Date	Doctor/Hospital	Investigation done	Outcome
a. How has your condition been treated?
Date	Therapy/Medication	Description/Dosage
b. Is future surgery planned/required/anticipated?	Yes	No
If yes, advise when?	D D M M Y Y Y Y
Has there been any improvement in your condition?	Yes	No
If yes, give details

How has this disability affected your ability to perform your daily living activities?
Washing	The ability to wash in the bath or shower (including getting into and out of the bath or shower) or wash by other means	Can	With help throughout	Cannot
Mobility	The ability to move indoors from room to room on level surfaces and outdoors for 200 m on level surfaces	Can	With help throughout	Cannot
Transferring	The ability to move from a bed to an upright chair or wheelchair and vice versa	Can	With help throughout	Cannot
Dressing	The ability to put on, take off, secure and unfasten all garments and, as appropriate, any braces, artificial limbs or other surgical appliances	Can	With help throughout	Cannot
Feeding	The ability to cut food as well as to get food and/or drink to the mouth	Can	With help throughout	Cannot
Toileting	The ability to use the lavatory or manage bowel and bladder functions through the use of protective undergarments or surgical appliances, if appropriate. This includes the maintenance of continence	Can	With help throughout	Cannot
Communicating	The ability to answer the telephone and take a message	Can	With help throughout	Cannot
Reading	Having the eyesight required to be able to read a newspaper, book or magazine	Can	With help throughout	Cannot
Bending and lifting	The ability to get into and out of a standard size car, bend, kneel or pick up something from the floor, lift, carry or move everyday objects	Can	With help throughout	Cannot
Co-ordination	The ability to use hands and fingers with precision, including the ability to pick up and manipulate small objects, such as pens or cutlery	Can	With help throughout	Cannot
Provide full details of your current daily activities
If this claim has arisen from an accident, please answer the questions below:
What was the date of the accident?	D D M M Y Y Y Y
How and where did the accident occur?
Police station where the accident was reported	Case no.
Declaration
I declare that 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. All the particulars given are, to the best of my knowledge, true and complete and I have not omitted or withheld any relevant information. Accepting that I am hereby curtailing my right of privacy, but to facilitate the assessment of risk, and the consideration of any claim for benefits: I irrevocably authorise Hollard Life: to obtain from any person, who I hereby authorise to supply, any information which Hollard Life deems necessary, and to share with other insurers that information and any information contained in this declaration or in any related policy or other document, either directly or through a database operated by or for insurers as a group, at any time (even after my death) and in such detailed, abbreviated or coded form as may from time to time be decided by Hollard Life or by the operations of such database.
Signature (claimant)	Date	D D M M Y Y Y Y
Full name of witness
Tel. no.	Cell no.
E-mail address	Mandatory
Signature (witness)	Date	D D M M Y Y Y Y