(To be completed by employer)
Please note that it is essential to complete this form in full to prevent unnecessary delays as a result of missing information. Return the completed form and the above documents to lifeclaims@hollard.co.za or fax to 086 659 0135.
Details of employer
Name of company
Physical address
Contact person
Tel. no.	Fax no.
E-mail address	Mandatory
Details of claimant
Full name
ID no.
Home tel. no.	Work tel. no.
Cell no.	Fax no.
E-mail address	Mandatory
Date joined the company	D D M M Y Y Y Y
Details of current employment
What is the claimant’s current position?
When was the claimant last able to perform his/her duties in full?	D D M M Y Y Y Y
Is the claimant still working?	Yes	No
If yes, give details of current activities
Is the claimant a full-time employee?	Yes	No
Date appointed to full-time staff	D D M M Y Y Y Y
Salary prior to date of disability	R
Is the claimant still receiving a salary?	Yes	No
Current salary amount	R
When do you intend ceasing this salary?	D D M M Y Y Y Y
When do you expect the claimant to resume work?
Part-time	D D M M Y Y Y Y	Full-time	D D M M Y Y Y Y
What do you understand to be wrong with your employee? (nature of illness/accident/injury)?
a. State the date of the first indication of disability	D D M M Y Y Y Y
b. State the nature of the first indication of disability

How does the disability affect the claimant’s ability to perform his/her duties?
Supply full details of the claimant’s sick leave (including days left) for the last 2 years, including copies of any medical certificates
Total number of days absent from work due to the above-mentioned illness/injury
Provide details (amount and time) of any advances or payments received by the employee from whatever source (e.g. from you, the employer, an insurance company, UIF or other source)
Experience and training
Provide a brief job history, including previous positions he/she held within your company
Date	Position held within company	Type of work done
From	To
Provide details of formal training and any qualifications or highest grade attained
Date	College or institution	Nature of training	Grade/Standard achieved
From	To
List any alternative duties within your organisation that the claimant could perform. In accordance with the revised Labour Relations Act, 1996, employers are obliged to be proactive in the realignment, reskilling and retraining of employees who are unable to perform their regular functions due to illness/accident/injury. Comment on any steps taken with regard to this particular member.
Job description
Summary of main duties
What equipment/machines/tools are used to perform this job (e.g. hammer, screwdriver, pen, pencil, computer, hydraulic lifts, etc.)?

Describe the minimum physical abilities that a healthy individual requires to do this job (e.g. percentages, kilograms, metres, hours, numbers (how much), bags or sacks (what)
What/Where	How much
Lift – kilograms
Carry – kilograms/metres
Push – kilograms/metres
Pull – kilograms/metres
Climb – metres
Stoop – percentage of day
Stand – percentage of day
Sit – percentage of day
Walk – percentage of day
Fine precise movement
Control of tools
Other
Describe the minimum mental abilities that a healthy individual requires to do this job (e.g. describe the tasks requiring mental activity or attach examples)
Abilities required	Very often	Often	Seldom	Examples of tasks requiring these abilities
Literacy
Numeracy
Memory
Problem solving
Decision making
Specialised knowledge
Describe the minimum communication skills required to do this job (e.g. describe the aspects requiring communication)
Communication skills required	Very often	Often	Seldom	Aspects of job requiring these communication skills
Speaking
Writing
Memory
Listening
Reading
Public speaking
Describe the work conditions (e.g. metres, percentages hours or actual descriptions)
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
What are the daily standard working hours?	Start time	End time
If shift work is required, provide details of alternate shift times	Start time	End time
Start time	End time

Declaration
We declare that the above information is true and correct to the best of our knowledge and that no information has been withheld and no relevant information regarding the circumstances has been omitted.
Completed by (full name and title)
Signature (employer)	Date	D D M M Y Y Y Y