HOW TO SUBMIT A DEATH CLAIM

Transcription

1 HOW TO SUBMIT A DEATH CLAIM For all GREENLIGHT and Living Assurance (Flexi) claims. We understand that at a time like this, you need all the support you can get. That s why we aim to process all valid claims as quickly as possible. THESE ARE THE STEPS to follow when claiming from your benefit. STEP 1: REPORT THE DEATH If the death has not been reported by the executor, bank, trust company, funeral parlour, etc., please report the death to your nearest Home Affairs office who will also provide you with the official death certificate. CONTACT DETAILS: CLAIMS SERVICE CENTRE OR +27 (0) Financial Advisers weekdays between 08:30-17:00 Home Affairs STEP 2: GATHER AND COMPLETE THE REQUIRED DOCUMENTS COMPULSARY REQUIREMENTS Certified copy of death certificate. Copies of ID or passport for the deceased and beneficiary(s) or a copy of the birth certificate if younger than 18. Proof of banking details for the beneficiary(s) or estate. We need a signed, dated and stamped statement from your bank that is not older than three months. A letter of executorship when the benefit is payable to the estate (in cases where there is no nominated beneficiary). DOWNLOAD AND COMPLETE THE FORMS LISTED ON THE NEXT PAGE. GREENLIGHT Care4U GREENLIGHT Care4U offers you a network of assistance in this time of need at no cost. Call to access any of the following services: Body repatriation from a local or international location to South Africa Assistance in obtaining a death certificate in the case of an unnatural death Referral to a pathologist Referral to providers of other funeral related services GREENLIGHT Care4U is only a phonecall away

2 CLICK ON THIS ICON TO GET THE FORMS Notification of death form (DHA 1663, formerly B11663) Old Mutual death claim form Old Mutual beneficiary form Additional documents for unnatural cause of death (excluding Final Expenses, Final Expenses Family Benefits) Old Mutual declaration by police Terminal Illness If the life covered is diagnosed with a medical condition which, according to Old Mutual s Chief Medical Officer, will result in death within 12 months, the Contracting Party may request the payment of a Terminal Illness Benefit. Old Mutual terminal illness form STEP 3: SEND THE DOCUMENTS TO OLD MUTUAL service@oldmutual.com Fax: +27 (0) Post: Death Claims Department, PO Box 1759, Mutualpark 7451, South Africa We ll let you know if we need any additional forms or documents Once we have received all the required documentation for a valid claim and approve the claim, we aim to pay: Final expenses death benefits within 48 hours All other death claims within 15 working days We would like you to get the right advice about investing your benefit payout and encourage you to speak to one of our accredited financial advisers about your investment optons. If you don t have a financial adviser please contact us. FOR FREQUENTLY ASKED QUESTIONS GO TO THE NEXT PAGE.

3 FREQUENTLY ASKED QUESTIONS Can I get a cash payout if I don t have a bank account or can I nominate a third party s bank account to receive the funds? If a beneficiary lives outside of South Africa, how will funds be paid? No, you will need to open a bank account in your own name in order to be paid a benefit. We will pay the funds into the beneficiary s blocked or non-resident account. If you don t have a blocked account, please contact your bank and apply for permission from the Exchange Control Authorities. When you have written permission from your bank, please submit a copy of the bank s permission as well as the following documents to Old Mutual: Fully completed Foreign Exchange Control questionnaire Copy of your passport Recent bank statement with an IBAN, SWIFT or SORT code Once we receive permission from the Reserve Bank, the funds will be paid to you. What is a DHA1663/BI1663 form and where do I get one? How do I certify a document? It is an official notification of death form that you will get from the funeral parlour or the doctor who certified the customer as deceased. Make a copy of the document. Take the copy and the original to your nearest commissioner of oaths (there are commissioners of oaths at police stations, legal offices, banks and Old Mutual branches) to be certified. The commissioner will stamp, date and sign the copy of the document. What must I do if no beneficiary was nominated or the deceased had no will? What is a letter of executorship and a letter of authority and where can I get one? How do I obtain the bank details for the estate of the deceased? There is a security cession on my policy or benefit, but the outstanding loan/bond has been settled. Do I need to include the cancelled cession to ensure any benefit is paid to the estate? The family or interested parties must decide whom to appoint as the executor. The appointed person has to collect the forms to apply for executorship from the Master of the High Court. When the court issues a letter of executorship, the executor can complete the required forms and submit the claim documents. The person who has been appointed as the executor must take the death certificate to the Master of the High Court and apply for a letter of executorship or a letter of authority, depending on the size of the estate. A letter of executorship or authority enables the executor to act on behalf of the estate. It can take four to six weeks for the Master of the High Court to issue the letter. A letter of executorship is needed if the value of the estate is more than R A letter of authority is needed if the value of the estate is less than R Once the letter of executorship or the letter of authority has been issued, the executor must go to a bank of his or her choice to open a bank account in the name of the estate. The executor will need to take along the death certificate, identity document of the deceased and a certified copy and the letter of executorship or authority. The executor will then have signing powers for that bank account. When the loan/bond was settled, the bank should have informed Old Mutual and the cession should have been removed. Please confirm with the bank. Must all estates be registered with the Master of the High Court? What is the difference between natural and unnatural death? Yes. For more information or to find your nearest office, go to or phone +27 (0) A natural death is primarily as a result of an illness or an internal malfunction of the body not directly influenced by external forces. An unnatural death is not properly describable as death by natural causes. It includes events such as accidents, drug abuse, execution or suicide. GREENLIGHT Product IM Old Mutual is a Licensed Financial Services Provider

4 DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA G.P.-S. 09/09 REPUBLIC OF SOUTH AFRICA DHA-1663 A DEPARTMENT OF HOME AFFAIRS Page 1 of 3 NOTICE OF DEATH / STILL BIRTH [Births and Deaths Registration Act 51 of 1992] [Regulations 11 and 14] BARCODE To be completed in full and submitted at the Department of Home Affairs' office by the informant or authorised funeral undertaker. The form to be completed in black ink with BLOCK LETTERS. Please mark with the CORRECT box, where required. All fields are COMPULSORY. Incomplete applications and applications that are not legible may be considered invalid. (Note: The fingerprints of the deceased, the informant and the undertaker must be taken by the undertaker) Serial number A. PARTICULARS OF THE DECEASED Instructions: Section A to be filled out by Authorised Medical Practitioner / Professional Nurse, who is responsible for examining the body to determine the cause of death. The Informant must verify, and where necessary, complete in full the personal particulars and other information of the deceased below. 1. Was this a death or a still birth? 1.1 Death 1.2 Still birth 2. Identification of the deceased (tick one box): 2.1 The deceased was identified with an ID document / passport (if foreigner) produced by the family 2.2 Still born child 2.3 The features of the deceased do not seem to match the features on the ID document or passport of deceased 2.4 ID document or passport of the deceased was not presented. The deceased was identified through word of mouth Left thumbprint of deceased 2.5 The deceased was already buried prior to the completion of this form 2.6 The deceased was unidentifiable: Burnt Decomposed Other (specify) DNA samples retrieved for identification purposes Dental records taken for identification purposes 3. Date of Death / still birth Y Y Y Y M M D D 4.1 Place of Death/still birth (City/Town/Village) 4.2 Province of Death/still birth 5. Place of Registration of Death / still birth int of deceased Right thumbpri 6. If death occurred within 24 hours after birth, number of hours alive 7. Home telephone no. 8. Identity No. (Passport No. if foreigner) 9. Age at last birthday if DOB is unknown 10. Date of Birth if there is no ID number Y Y Y Y M M D D 11. Gender 11.1 Male 11.2 Female 11.3 Indeterminable 12. Surname 13. Previous / Maiden Surname 14. Forenames 15. Usual* Residential Address: Street Town Province 16. Citizenship 16.1 Place of Birth (City / Town / Village) or Country of Birth, if abroad 16.2 Province of Birth 17. Marital Status of the deceased 17.1 Single 17.2 Married 17.3 Widowed 17.4 Divorced 18. Education level of deceased, (Specify only the highest class completed) Non e Gr R Gr 1 Gr 2 Gr 3 Gr 4 Gr 5 Gr 6 Gr 7 Gr 8 Form Gr 9 Gr 10 1 Form 2 Form 3 NTC 1 Gr 11 Form 4 NTC 2 Gr 12 Form 5 NTC 3 Univ Tech Unk now n (mark with a ) 19. Usual occupation of deceased (type of work done during most of working life) 20. Type of business / industry: 1. Agriculture, hunting, forestry and fishing 2. Mining and quarrying (mark with a ) 3. Manufacturing 4. Electricity, gas and water supply 5. Construction 6. Wholesale and retail trade; repair of motor vehicles, motor cycles and personal and household goods; hotels and restaurants 7. Transport, storage and communication 8. Financial intermediation, insurance, real estate and business services 9. Community, social and personal services 10. Private households, exterritorial organisations, representatives of foreign governments & other activities not adequately defined 21. Was the deceased a regular** smoker five years ago? (mark with a ) 21.1 Yes 21.2 No 21.3 Do not know 21.4 Not applicable (minor) * Where the deceased lived on most days. **Smoking tobacco on most days.

5 DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA G.P.-S. 09/09 REPUBLIC OF SOUTH AFRICA DHA-1663 A DEPARTMENT OF HOME AFFAIRS Page 2 of 3 NOTICE OF DEATH / STILL BIRTH [Births and Deaths Registration Act 51 of 1992] [Regulations 11 and 14] BARCODE To be completed in full and submitted at the Department of Home Affairs' office by the informant or authorised funeral undertaker. The form to be completed in black ink with BLOCK LETTERS. Please mark with the CORRECT box, where required. All fields are COMPULSORY. Incomplete applications and applications that are not legible may be considered invalid. (Note: The fingerprints of the deceased, the informant and the undertaker must be taken by the undertaker) Serial number B. CERTIFICATE BY ATTENDING MEDICAL PRACTITIONER / PROFESSIONAL NURSE Instructions: Section B to be filled out by the same Medical Practitioner / Professional Nurse who completed Section A I, the undersigned, hereby certify that the deceased named in Section A, to the best of my knowledge and belief, died solely and exclusively due to Natural Causes 22.2 I, the undersigned, am not in a position to certify that the deceased died exclusively due to Natural Causes Particulars of the Medical Practitioner / Professional Nurse who filled out the form: 23. HPCSA Registration No. 24. Surname 25. Forenames 26. Name of Health Facility / Practice 27. Facility / Practice No. 28. Business Address: Street Town Province Telephone No. (Office) Postal Code Office stamp of health facility or practice I, the undersigned, hereby certify that I examined the body of the deceased named in section A and declare that the deceased, to the best of my knowledge and belief, died solely and exclusively due to natural or unnatural causes as indicated on paragraph 22 and in case this is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.) Place signed Date signed Y Y Y Y M M D D Signaturet C. CERTIFICATE BY MEDICAL PRACTITIONER/ FORENSIC PATHOLOGIST Instructions: Section C to be filled out by Medical Practitioner or Forensic Pathologist, who is conducting medico-legal investigation of death. 29. I, the undersigned, hereby certify that a medico-legal investigation of death has been conducted on the body of the person whose particulars are given in Section A and that the body is no longer required for the purpose of the Inquest Act, 1959 (Act No. 58 of 1959) and the cause of death is: 30.1 Natural 30.2 Unnatural 30.3 Under investigation 31. Date of Post-mortem Y Y Y Y M M D D 32. Name of Medico-legal Mortuary / Mortuary 33. Mortuary No. 34. Mortuary Reference Number of Deceased 35. SAPS Case No. 36. Name of Police Station Particulars of the Medical Practitioner / Forensic Pathologist who filled out the form: 37. Surname HPCSA Registration No. 38. Forenames 39. Business Address Street Town Province Postal Code Telephone No. (Office) Office stamp of mortuary I, the undersigned, hereby certify that I examined the body of the deceased named in section A and the deceased, to the best of my knowledge and belief, died solely and exclusively due to natural or unnatural causes as indicated on paragraph 29 and in case this is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.) Place signed Date signed Y Y Y Y M M D D Signature D. PARTICULARS OF INFORMANT Instructions: Section D to be completed by informant. Informant is responsible for certifying the identity of the deceased. 40. Identity No. (Passport No. if foreigner) 41. Date of Birth Y Y Y Y M M D D 42. Citizenship 43. Surname 44. Forenames 45. Residential Address: Street Town Province Telephone No. (Home) Postal Code Cellphone No. Left thumb print of informant 46. The Deceased is my: 46.1 Parent 46.2 Spouse 46.3 Child 46.4 Other, Specify I, the undersigned, hereby certify that the identity of the deceased mentioned in section A is to the best of my knowledge and belief true and correct in case it is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.) Signature Date signed Y Y Y Y M M D D Place signed

6 DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA G.P.-S. 09/09 E. PARTICULARS OF FUNERAL UNDERTAKER 47. Name of Funeral Parlour REPUBLIC OF SOUTH AFRICA DHA-1663 A DEPARTMENT OF HOME AFFAIRS Page 3 of 3 NOTICE OF DEATH / STILL BIRTH [Births and Deaths Registration Act 51 of 1992] [Regulations 11 and 14] To be completed in full and submitted at the Department of Home Affairs' office by the informant or authorised funeral undertaker. The form to be completed in black ink with BLOCK LETTERS. Please mark with the CORRECT box, where required. All fields are COMPULSORY. Incomplete applications and applications that are not legible may be considered invalid. (Note: The fingerprints of the deceased, the informant and the undertaker must be taken by the undertaker) 48. DHA Designation No. 49. Company Reg. No. BARCODE Serial number Instructions: Section E to be completed by Funeral Undertaker. The undertaker must take his or her finger print, the finger print of the deceased and the informant. Authorised Funeral Undertaker or Informant may submit the completed form to the nearest Home Affairs office. 50. SARS Reg. No. (Income tax reference no.) Details of Funeral Undertaker or Authorised Representative 51. Identity N No. (Passport t No. if foreigner) 52. Surname 53. Forenames 54. Business Address Street Town Province Postal Code ertaker Left thumbprint of funeral unde Telephone No. (Office) Cellphone No. 55. Date of collection of corpse Y Y Y Y M M D D 56. Date of Cremation (if applicable) Y Y Y Y M M D D 57. Place of Burial (City / Town / Village) Province 58. Date of Burial Y Y Y Y M M D D 59. Grave No. (if available) Name of person who collected the deceased: Office stamp of funeral undertaker 60. Identity No. (Passport No. if foreigner) 61. Surname 62. Forenames Place signed Date signed Y Y Y Y M M D D Signature F. FOR OFFICIAL USE ONLY Registration of death approved, DHA-1663 received by (particulars of DHA official): 63. Identity No. Office stamp of DHA 64. Surname 65. Forenames 66. Persal No. Documents included with this notice: Copy of the deceased's ID Copy of ID document of the informant DHA - 6 (if applicable) DHA (if applicable) DHA-1663 was submitted by: Informant Funeral Undertaker

7 RSA DEATH CLAIM FORM FOR DEATH/FINAL EXPENSES/ FUNERAL CLAIMS Policy number Please print in block letters using black or blue ink. For all claims questions, call or 27 (0) weekdays between 08:00 and 18:00 or To be filled in by the contact person To process claims efficiently, we may need to contact someone at various stages of the claim. If you are the person we must contact, please fill in this form. You do not need to be a beneficiary of this death claim to complete this form but you must be the contact person. Beneficiaries must complete the separate BENEFICIARY FORM. If you are both the contact person as well as the beneficiary, you must fill in this form as well as the BENEFICIARY FORM. To find out exactly what documents you need to provide us with for your claim, please ask for our HOW TO SUBMIT A DEATH CLAIM information page. The contact person is responsible for providing information that is true and accurate, to the best of your knowledge. At the end of this form, you need to sign to indicate that you have given us true and correct information. You also need to sign your permission for us to confirm your information with any other source. 1. CONTACT PERSON S DETAILS Title Mr Ms Mrs Other Initials First names Surname ID number Relationship to the deceased: Family member Executor of estate Other (please explain) Contact numbers (Work) Code Number (Home) Code Number Fax Code Number Cellphone number address Residential address if different to postal address Postal address Are you also a beneficiary of this policy? YES NO If YES, please fill in the separate BENEFICIARY FORM. 2. DETAILS OF DECEASED To confirm information about the deceased, we need to know the following information about the deceased: Title Mr Ms Mrs Other Initials First names Surname South African ID or passport number Income tax number Date of birth D D M M Y Y Y Y Date of death D D M M Y Y Y Y Cause of death: Natural (i.e. old age or illness) Unnatural (i.e. car accident or victim of crime) Please provide more information about the cause of death. Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06 1 Death Claim & Beneficiary Claim Form omms L6937

8 Was the deceased insured with any other company? YES NO Company name Company name Policy number Policy number 3. MEDICAL INFORMATION a) Please fill this section in. We may need to contact the person who certified the death. Please provide the name of the hospital or medical practitioner who certified the death. Name of hospital Contact person Telephone Code Number Cellphone number address Address b) Medical history of deceased Please provide the names and addresses of the deceased s house doctor and any other doctor, hospital or clinic where the deceased received medical attention. Name Address Approximate date of medical attention D D M M Y Y Y Y Reason for medical attention. Name Address Approximate date of medical attention D D M M Y Y Y Y Reason for medical attention. Name Address Approximate date of medical attention D D M M Y Y Y Y Reason for medical attention. c) Medical Aid details of deceased Did the deceased belong to a medical aid? YES NO Name of Medical Aid Contact numbers Member number address Policy number Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06 2 Death Claim & Beneficiary Claim Form omms L6937

9 4. FUNERAL PARLOUR INFORMATION We may need to contact the undertaker. Please fill this section in. Name of funeral parlour Contact person Telephone Code Number Cellphone number address Address 5. EMPLOYER INFORMATION We may need to contact the employer. Please fill this section in. Name of employer Contact person Telephone Code Number Cellphone number address Address 6. DECLARATION OF CONTACT PERSON I confirm that all the information provided on this form is true and accurate to the best of my knowledge. I give Old Mutual consent to confirm the information provided with any other source. Signed at this day of 20 Signature of contact person CORRESPONDENCE DETAILS Send documents to Old Mutual: Fax Post service@oldmutual.com (attached confirming fax number) Death Claims Department PO Box 1759 Cape Town 8000 South Africa Policy number Old Mutual is a Licensed Financial Services Provider Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06 3 Death Claim & Beneficiary Claim Form omms L6937

10 RSA BENEFICIARY CLAIM FORM FOR DEATH/FINAL EXPENSES/ FUNERAL CLAIMS Policy number Please print in block letters using black or blue ink. For all claims questions, call or 27 (0) weekdays between 08:00 and 18:00 or To be filled in by the beneficiary or beneficiaries Each beneficiary must fill in this form. If there is more than one beneficiary, each beneficiary must fill in a separate form. If you are also the contact person for a claim, please fill in the CONTACT FORM FOR DEATH/ FINAL EXPENSES/FUNERAL CLAIMS. To find out exactly what documents you need to provide us with for your claim, please ask for our HOW TO SUBMIT A DEATH CLAIM information page. 1. BENEFICIARY DETAILS Title Mr Ms Mrs Other Initials First names Surname ID number Income tax number Relationship to the deceased: Family member Executor of estate Other (please explain) Contact numbers (Work) Code Number (Home) Code Number Fax Code Number Cellphone number address Residential address if different to postal address Postal address 2. BENEFICIARY BANK ACCOUNT DETAILS Name of bank Name of account holder Branch name Branch code Account number Account type Current Savings Transmission Swift/BAN/Sort code (for foreign bank accounts only) We pay all claims by EFT into each beneficiary s bank account. We don t pay in cash or by cheque. If you don t have a bank account, you need to open one. The bank account must be in your name. We do not pay into third party accounts. If you are a minor, you still need a bank account in your name. We need you to apply for permission from the South African Reserve Bank before we can pay into a foreign bank account. We are not responsible if we pay into an incorrect bank account based on incorrect banking information you gave us. 3. DECLARATION OF BENEFICIARY I confirm that the information I have provided on this form is true and correct to the best of my knowledge. I agree that I cannot hold Old Mutual responsible if any money is paid into an incorrect bank account as a result of any information I have given. I give Old Mutual consent to confirm the information on this form with any other source. Signed at this day of 20 Signature of beneficiary PROTECTION OF PERSONAL INFORMATION (PPI) The Old Mutual Group would like to offer you, on-going financial services and may use your personal information to provide you with information about products or services that may be suitable to meet your financial needs. Please sms your ID number to if you would prefer not to receive such information and financial services. To view our full privacy notice and to exercise preferences, visit our website on Old Mutual is a Licensed Financial Services Provider Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06 4 Death Claim & Beneficiary Claim Form omms L6937

11 RSA BENEFICIARY CLAIM FORM FOR DEATH/FINAL EXPENSES/ FUNERAL CLAIMS Policy number Please print in block letters using black or blue ink. For all claims questions, call or 27 (0) weekdays between 08:00 and 18:00 or To be filled in by the beneficiary or beneficiaries Each beneficiary must fill in this form. If there is more than one beneficiary, each beneficiary must fill in a separate form. If you are also the contact person for a claim, please fill in the CONTACT FORM FOR DEATH/ FINAL EXPENSES/FUNERAL CLAIMS. To find out exactly what documents you need to provide us with for your claim, please ask for our HOW TO SUBMIT A DEATH CLAIM information page. 1. BENEFICIARY DETAILS Title Mr Ms Mrs Other Initials First names Surname ID number Income tax number Relationship to the deceased: Family member Executor of estate Other (please explain) Contact numbers (Work) Code Number (Home) Code Number Fax Code Number Cellphone number address Residential address if different to postal address Postal address 2. BENEFICIARY BANK ACCOUNT DETAILS Name of bank Name of account holder Branch name Branch code Account number Account type Current Savings Transmission Swift/BAN/Sort code (for foreign bank accounts only) We pay all claims by EFT into each beneficiary s bank account. We don t pay in cash or by cheque. If you don t have a bank account, you need to open one. The bank account must be in your name. We do not pay into third party accounts. If you are a minor, you still need a bank account in your name. We need you to apply for permission from the South African Reserve Bank before we can pay into a foreign bank account. We are not responsible if we pay into an incorrect bank account based on incorrect banking information you gave us. 3. DECLARATION OF BENEFICIARY I confirm that the information I have provided on this form is true and correct to the best of my knowledge. I agree that I cannot hold Old Mutual responsible if any money is paid into an incorrect bank account as a result of any information I have given. I give Old Mutual consent to confirm the information on this form with any other source. Signed at this day of 20 Signature of beneficiary PROTECTION OF PERSONAL INFORMATION (PPI) The Old Mutual Group would like to offer you, on-going financial services and may use your personal information to provide you with information about products or services that may be suitable to meet your financial needs. Please sms your ID number to if you would prefer not to receive such information and financial services. To view our full privacy notice and to exercise preferences, visit our website on Old Mutual is a Licensed Financial Services Provider Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06 1 Contact Form for Death & Funeral Claims omms L6937

12 Terminal Illness Claim Form GREENLIGHT Please print in block letters using black or blue ink. This form is issued without admission of liability and must be signed by the claimant and forwarded to: GREENLIGHT Service Centre PO Box 202 Mutualpark 7451 South Africa Tel: Fax: GUIDELINES ON SUBMISSION OF A CLAIM: PART 1 Must be completed and signed by the claimant/contracting Party where appropriate. PART 2 Must be completed and signed by the claimant s attending doctor. IMPORTANT: PLEASE CONTINUE PAYING YOUR MONTHLY CONTRIBUTIONS TO AVOID BENEFITS CEASING. PART 1 TO BE COMPLETED BY THE CLAIMANT CONTRACTING PARTY DETAILS Title: Mr Ms Mrs Other Initials Surname/ Name of institution First names/ Contact person Previous surname (if applicable) ID number/institution registration number Passport number (where no South African ID number is available) Country of issue of passport Date of birth Age next birthday Gender: Male Female Income tax number Residential address/ Physical address of institution Are you a South African resident? Yes No Postal address Telephone (W) Code No. (H) Code No. Fax Code No. Cellphone number address Marital status: Single Married Divorced Widowed Correspondence Language: English Afrikaans The Financial Services Charter requires life insurance companies to report on the racial spread of their client bases. Please assist us to fulfil our obligations under the Charter by indicating to us the race group to which you feel you belong. This information will be used only for determining (and reporting on) the racial spread of our client base. Race: Black Indian Coloured White BANKING DETAILS Name of bank Branch name Branch code Accountholder name Account number Account type Cheque Savings Transmission Accountholder relationship Own account Joint account 3rd Party account 1 GL Terminal Illness Claim OMMS T2928

13 DECLARATION PROTECTION OF PERSONAL INFORMATION (PPI) NOTICE The Old Mutual Group would like to offer you ongoing financial services and may use your personal information to provide you with information about products or services that are suitable to your financial needs. Please sms your ID number to if you do not want to receive such financial services. We may use your information or obtain information about you for the following purposes: Underwriting Assessment and processing of claims Credit searches and/or verification Claims checks (ASISA Life & Claims Register) Fraud prevention and detection Market research and statistical analysis Audit & record keeping purposes To comply with legal & regulatory requirements Verifying your identity Sharing with service providers we engage to process information on our behalf You may access the information that we hold about you and ask us to correct any errors or delete the information we have about you. To view our full privacy notice and to exercise preferences, visit our website on I irrevocably authorise: (a) Old Mutual to obtain from any person any information which Old Mutual needs, according to its practice from time to time, to assess this claim. (b) the person concerned to give Old Mutual the information which Old Mutual requests under the authorisation in (a), and I request that person to do so. (c) Old Mutual to give to other insurers to assess risk or claims, and to the Life Offices Association of South Africa (LOA), any information obtained by Old Mutual under the authorisation in (a), as well as any information contained in any document or contract to which this claim relates. (d) the LOA to give any such information received from Old Mutual to other insurers to assess risk or claims. Any information may, under this authorisation, be obtained or given at any time, even after my death, and in such detail, or in such abbreviated or coded form, as Old Mutual or the LOA may from time to time decide. I understand that my right to privacy is curtailed to the extent permitted by me in this authorisation. This information may be used by Old Mutual to determine the validity of this claim. By signing below, I certify that I agree to the prepayment of the death benefits under the abovementioned plan(s). I understand that if my request for this prepayment is approved, the full cover amount of the death benefit(s) will be payable as full and final settlement of these benefit(s). I understand that the benefit(s) will cease after this payment. Signature of claimant Date D D M M Y Y Y Y PART 2 TO BE COMPLETED BY THE ATTENDING DOCTOR A terminal illness is defined as a medical condition that. with reasonable medical certainty in the opinion of Old Mutual s Chief Medical Officer, will result in the death of the life assured within twelve months of the date medical evidence to that effect is provided. Date of first visit Date of last visit D D M M Y Y Y Y D D M M Y Y Y Y Diagnosis A. Present condition Please provide us with sufficient detail of the claimant s present condition to support that a reasonable assessment of the life expectancy of the claimant is less than twelve months. B. General 1. Please indicate the terminal illness from which the claimant is suffering, with the appropriate international staging of the disease, where applicable. To support the claim, please provide us with copies of all tests, investigations and reports in your possession. 2 GL Terminal Illness Claim OMMS T2928

14 2. If the claimant is suffering from Carcinoma, please provide us with a copy of the histology report and a detailed staging of the disease to enable Old Mutual to arrive at the appropriate decision. 3. If the claimant is HIV positive, please advise the current stage. I certify that I have personally attended the patient and that all the foregoing statements are correct to the best of my knowledge. Initials Surname Qualifications Address Practice number Name of hospital Address of hospital Telephone Code No. Fax Code No. Signed at this day of year Signature of medical attendant Date D D M M Y Y Y Y Plan number(s) 3 GL Terminal Illness Claim OMMS T2928

15 DECLARATION BY POLICE Licensed Financial Services Provider Old Mutual Life Assurance Company (South Africa) Limited reg. no.: 1999/004643/06 DETAILS OF THE DECEASED Please print in block letters using black or blue ink. To be completed by the investigating officer at the police station where the death of the deceased was reported. This certificate is required to substantiate a death claim and will be considered strictly confidential. Policy number(s): First name(s): Surname: Date of birth: INVESTIGATING OFFICER S REPORT 1. (a) Date, time and place of death: Date of death: Time of death: : Place: (b) Magisterial district: (c) Who identified the deceased? (d) What is this person s relationship to the deceased Date identified: 2. Is it suspected that the death was due to suicide? YES NO 3. Was the deceased involved in a motor vehicle accident? YES NO (a) Was the deceased a: driver passenger or pedestrian? (b) If driver, was the deceased in possession of a valid driver s licence? YES NO - Driver s licence code - Date issued - Valid until (c) Was a blood alcohol test done on the deceased? YES NO (d) Results of blood alcohol test: (e) Are there any witnesses to the accident? YES NO (Attach a copy of the test result) (Attach a copy of the full road traffic accident report) 4. Was the deceased involved in an assault? YES NO (a) Was the deceased assaulted during the course of his/her duties? YES NO (b) Was the deceased an innocent bystander? YES NO (c) Did the deceased provoke the incident? YES NO Page 1 of 3

16 5. Was the deceased involved in a shooting accident? YES NO (a) If Yes, did the deceased take his/her own life intentionaly? YES NO OR (b) Did a shooting accident occur? YES NO (c) Is anyone being held responsible for the accident? YES NO 6. Was an autopsy done? YES NO (a) If Yes, name of medico-legal laboratory where autopsy was performed. (b) Date the autopsy was performed on. (c) Death register number. (d) Name of doctor who performed the autopsy. (e) Telephone number of this doctor. (f) What the cause of death was as determined by the autopsy. (g) Height Build Mass Nutritional state (h) Were any specimens kept? YES NO If yes, type of specimen Examination Detail (i) Serial number of medical certificate re cause of death issued 7. Has an inquest been or will one be held? (a) If Yes, name of court: YES NO (b) Date of inquest: (c) Inquest number and reference: 8. Have criminal proceedings been or will criminal proceedings be instituted? (a) What was the charge? YES NO (b) Who was charged? (c) If judgement has been given, what was the verdict? (d) Is there any suspicion or probability of family involvement in the death of the deceased? YES NO 9. Name of the police station where death was reported: (a) Case reference number: (b) Investigating officer: 10. Please attach copies of all affidavits already obtained in respect of this investigation Page 2 of 3 The Green Room WT258934

17 11. Please give a short description of the circumstances of death. Signed at this day of 20 Official stamp Signature of investigating officer PLEASE PRINT: Name: Rank: Telephone number: ( ) Please send this form, when completed, directly to: Death Claims Department Old Mutual PO Box 1759 Cape Town Page 3 of 3 The Green Room WT258934