Transcription of Regent Life Assurance Company Ltd. Claims …
1 Regent Life Assurance Company Ltd. Claims department Head Office Block: 146 Boeing Road East, Elma Park, Edenvale, 1609. PO Box 674, Edenvale, 1610. T: +27 (0)11 879 5000 | F: +27 (0)11 574 2847 | E: CLM 106 - Police Page 1 of 1 CLM 106 - POLICE REPORT TO BE COMPLETED BY THE INVESTIGATING OFFICER AND WILL BE CONSIDERED STRICTLY CONFIDENTIAL This report is to assess a death claim under a policy issued by Regent LIFE on the life of: 1. a) Name of deceased (in full): b) Date, time and place of death: c) Magisterial district: 2. Was the deceased involved in a motor vehicle accident? a) Was the deceased a driver, passenger or pedestrian? b) Was a blood-alcohol test done?_____ 3. Was the deceased involved in an assault?
2 A) Was the deceased assaulted in the course of his duty? b) Was the deceased an innocent bystander? 4. Was a post mortem carried out? If so, what were the findings? _____ 5. Is suicide suspected? _____ 6. Has or will an inquest be held? a) Name of Court: b) Date of inquest: c) Inquest number and reference: 7. Have or will criminal proceedings be instituted? a) What was the charge? b) Who was charged? c) If judgment has been given, the verdict: d) Name of Court: e) Date of trial: f) Trial number and reference: 8. Name of police station where death was reported: a) Case reference number: b) Investigating Officer: 9. Please give a short description of the circumstances of death: _____ _____ DATED AT: THIS DAY OF 20 TELEPHONE NUMBER: CODE: FACSIMILE NUMBER: CODE: SIGNATURE OF INVESTIGATING OFFICER: NAME: _____RANK_____
