Funeral Claim Application & Discharge
The following documentation is required:
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A fully completed claim form;
A certified copy of the Identity Document of the deceased Assured Person;
A certified copy of the Death Certificate of the deceased Assured Person;
A certified copy of the Identity Document of the Claimant( If not company);
A copy of the form BI 1663;
If a stillborn child, a letter from the doctor confirming length of pregnancy;
Every accidental death claim will require a police report;
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In the case of a Spouse, marriage certificate or an affidavit satisfactory to The Best Funeral Society;
In the case of a legitimate biological child, a certified copy of the Participant's or Spouses Identity Document
and marriage certificate and child's birth certificate;
In the case of a stepchild, a certified copy of the relevant marriage certificate and the Child's birth certificate;
In the case of an illegitimate or adopted child, a copy of the adoption certificate, an affidavit or any other
documentary proof satisfactory to The Best Funeral Society;
All copies shall be certified by a Commissioner of Oaths and originally certified copies to be sent to The Best
Funeral Society.
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Please complete all details required on both pages.
Incomplete details may cause delays and be requested again later.
Claimant Details
Claimant’s Full Names
Claimant’s Surname
Identity No.
Tel. (H.)
Street Address
Date Of Birth
Employer
Tel. (W.)
Postal Code
Postal Address
Postal Code
Relationship To Deceased
Deceased Details
Scheme Name
Deceased Full Names
Policy No.
Deceased Surname
Identity No.
Tel. (H.)
Street Address
Date Of Birth
Main Members Name
Tel. (W.)
Postal Code
Postal Address
Postal Code
Details Of Death
Date Of Death
Police Case
No.
Date Of Funeral
Name Of Undertaker
Undertakers Tel. No.
Certifying Doctor
Doctors Contact No’s.
Place Of Death
Police Station
Burial Cemetery
Cause Of Death
Hospital Admission No.
Undertakers Address
Doctors Address
Other Applicable Information
All benefits are administered by The BEST Funeral Society (Pty) Ltd. Reg. No. 1997/005812/07 and underwritten by Hollard Life Assurance Company
Limited Reg. No. 1993/001405/06. Both are Authorized Financial Service Providers
Payment Details & Indemnity
In my capacity as claimant, I the undersigned acknowledge that all details provided are correct, and that I am the valid
recipient of any benefit payment. I further understand that any misstatement or non-disclosure which materially affects the
assessment of this claim, may cause settlement of the claim to be declined or delayed.
I request payment be made as follows:
Full Payment To :
___________________________________________________________________________________
OR
Part Payments To : ________________________________________________ Amount (R
.
)
________________________________________________ Amount (R
.
)
Signature :
Bank Details
Bank :
Acc No :
_________________________________________
Branch :
Acc Holder:
and
Date : ____________________
Brch. Code:
Acc Type:
Should you have any questions with regard to the completion of this form, please
contact the claims department on 0860 101 303, or
The Best Funeral Society (Pty) Ltd.
Tel: (011) 373 8400 Fax : (011) 836 8573
P O BOX 57036
SPRINGFIELD
2137
All benefits are administered by The BEST Funeral Society (Pty) Ltd. Reg. No. 1997/005812/07 and underwritten by Hollard Life Assurance Company
Limited Reg. No. 1993/001405/06. Both are Authorized Financial Service Providers
D e c lar ation b y Po lice
Please return to: P.O. Box 57036, Springfield, 2137
TO BE COMPLETED BY THE INVESTIGATING OFFICER AT THE POLICE STATION WHERE THE
ACCIDENT WAS REPORTED
HOLLARD LIFE ASSURANCE COMPANY on the life of the person mentioned below and will be considered strictly confidential.
DETAILS OF THE LIFE ASSURED
Policy number
……………………………………………………………………………………………..
Surname
……………………………………………………………………………………………..
Full names
……………………………………………………………………………………………...
Date of Birth
……………………………………………………………………………………………...
I.D. number
……………………………………………………………………………………………..
DETAILS OF THE ACCIDENT OF THE LIFE ASSURED
Date and time of the accident
……………………………………………………………………………………………..
Place of the accident
…………………………………………………………………………………………….
Cause of the accident
…………………………………………………………………………………………….
Magisterial district
…………………………………………………………………………………………….
Police station where accident was reported
…………………………………………………………………………………………….
Case number
……………………………………………………………………………………………..
Date reported
……………………………………………………………………………………………..
Name of investigating officer
……………………………………………………………………………………………...
1.
Was the life assured involved in a motor accident? …………………………………………………………………………
(a) Was the life assured a driver, passenger or pedestrian? ……………………………………………………………………….
(b) Was a blood alcohol test done on the life assured...…………………………………………………………………………..
(c) Results of blood alcohol test? ………………………………………………………………………………………………..
2.
Was the life assured involved in an assault? …………………………………………………………………………………
(a) Was the life assured assaulted during the course of his/her duties? ………………………………………………………….
(b) Was the life assured innocent bystander? ……………………………………………………………………………………
3.
Has an inquest been held or will one be held? ………………………………………………………………………………
(a) Name of court …………………………………………………………………………………………………………….…
(b) Date of inquest held/to be held ……………………………………………………………………………………………..
All benefits are administered by The BEST Funeral Society (Pty) Ltd. Reg. No. 1997/005812/07 and underwritten by Hollard Life Assurance Company
Limited Reg. No. 1993/001405/06. Both are Authorized Financial Service Providers
(c) Inquest number and reference………………………………………………………………………………………………
4. Have/Will criminal proceedings been/ be instituted?………………………………………………………………….
(a) If yes, name of person charged ……………………………………………………………………………
(b) What were / are the charges?………………………………………………………………………………
(c) If judgment was given, what was the verdict?……………………………………………………………
(d) Which court? ………………………………………………………………………………………………
(e)
Date of trial (DDMMYY)?…………………………………………………………………………………
(f)
Trial and reference number…………………………………………………………………………………
(g) Give a short description of the circumstances of the accident………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
DECLARATION
I declare that all the a foregoing statements are true and correct.
Date (DDMMYY) …………………………………………..
Station…………………………………………………………………..
Telephone number (…………)……………………………..
Cell No…………………………………………
Name ………………………………………………..……....
Signature ………………………………………
Rank & Rank No. ………………………………………
Stamp
All benefits are administered by The BEST Funeral Society (Pty) Ltd. Reg. No. 1997/005812/07 and underwritten by Hollard Life Assurance Company
Limited Reg. No. 1993/001405/06. Both are Authorized Financial Service Providers