(To be completed by the life assured, the trustees of the trust or directors of the company)
Please note that it is essential to complete this form in full to prevent unnecessary delays as a result of missing information. The following copies must be included when submitting this form along with any other pertinent information to this claim: For a trust, we require sight of the trust deed and certified copies of the trustees’ IDs. For a company-owned policy, we require sight of the company CK document and resolution of authorised signatories. Return the completed form and the above documents to lifeclaims@hollard.co.za or fax to 086 659 0135.
Details of life insured
Policy no.	ID no.
Full name
Details of policy owner
Full name
ID no.
Tel. no.	Cell no.
E-mail address
Postal address
Declaration by policy owner
I confirm that I legally represent the policy owner. I am aware that the life insured has submitted a claim to Hollard Life on behalf of the policy owner. I have requested the life insured to complete the claimant form and provide all the medical information required to assess the critical illness/disability claim.
Signature (policy owner)	Date	D D M M Y Y Y Y