Transcription of CLAIM NOTIFICATION FORM - Universal
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CLAIM NOTIFICATION FORM - Universal
POLICYHOLDER DETAILSPOLICYHOLDER:MEMBER GROUP NUMBER:SCHEME NUMBER:PRINCIPAL MEMBER NAME:DECEASEDName of the deceased: ID no. of the deceased: Date of death: DDMMYYYYAge at death:Relationship of deceased to the principal member: SETTLEMENT OF BENEFIT:Cheque:Electronic Funds Transfer:ChequeElectronic Funds TransferPayable to:Bank Account Holder:Relationship to deceased:Bank Name:Cheque will be collected by:Branch Name:It is important that the Beneficiary presents their original Identity Document (South African Citizen) or Passport (foreign national) when collecting a cheque from any Safrican Offices. Drivers licence cards will not be Account Number:Branch Code:ADDRESSES FOR SENDING ALL CLAIM CORRESPONDENCECOMPANY STAMPP ostal address: Postal code:Fax: E-mail:Tel: Date:DDMMYYYYName and Signature of the Policyholder/ Claimant Designation(For claiming purposes post, fax or e-mail this page only see page 4 for contact details) Safrican Insurance Company Limited.
DOCUMENTATION TO BE SUBMITTED WITH THE CLAIM NOTIFICATION FORM 1. Proof of Death: • (BI-5) Original computer produced or …
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