When dealing with the unexpected loss of a loved one, managing the intricacies of insurance claims can often add to an already overwhelming situation. The Claim Application Discharge Hollard form is designed to navigate such complexities, ensuring that the claim process is as smooth and comprehensible as possible. This comprehensive form guides claimants through multiple sections, starting with validating the claimant's understanding and agreement to the terms laid out by Hollard, to the provision of detailed information about the policy holder and the deceased. It encompasses everything from personal identification to employment details of the departed, including crucial information surrounding the circumstances of death, and the specifics of the funeral service. Crucially, this form also touches on the consent required to access and share sensitive information, which is vital for the processing of the claim. To complete the claim, it details the method of transferring the agreed claim amount to the claimant, ensuring that all necessary financial information is clearly communicated. Designed with the intention of making a difficult time slightly easier, this form represents a critical step in finalizing the affairs of the deceased with Hollard.
Question | Answer |
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Form Name | Claim Application Discharge Hollard Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | funeral form for work, burial society membership form, bi 1663 form no download needed, bi 1663 form sample |
CLAIMS APPLICATION & DISCHARGE
HOLLARD FUNERAL PLAN
FAX - |
COMPLETED & SIGNED DOCUMENTS TO |
OR |
EMAIL - |
TO lifeclaimsadmin@hollard.co.za |
OR |
POST ORIGINALS - |
LIFE CLAIMS – PO Box 87428 – Houghton - 2041 |
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SECTION 1
VALIDATION AND CONFIRMATION
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, the claimant on this policy, confirm that I have |
(i)Read, (ii) understand, (iii) agree, (iv) and will adhere to the requirements noted as Section 1, which is outlined on the original faxed cover sheet submitted to me by HOLLARD, which lists the requirements of the claim.
(Note that the first page of the fax is not to be faxed with the claim form and required documents. Should you not agree to any of the noted points, please highlight and circle the specified number. E.g. “i”, “ii”, “iii” or “iv” and submit a reason signed in the presence of a Commissioner of
Oaths.) |
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SECTION 2 |
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CONTRACT INFORMATION |
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SCHEME NAME |
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Signature of Claimant |
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POLICY NUMBER |
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INFORMATION OF THE POLICY HOLDER |
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SURNAME |
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FULL NAMES |
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ID NUMBER |
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SECTION 3 |
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INFORMATION OF DECEASED / LATE |
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SURNAME |
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FULL NAMES |
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ID NUMBER |
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RESIDENTIAL ADDRESS OF LATE |
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POSTAL ADDRESS OF |
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LATE |
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POSTAL CODE |
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POSTAL CODE |
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WORK |
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TELEPHONIC AND ELECTRONIC |
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HOME |
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CONTACT INFORMATION |
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CELL |
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SECTION 4 |
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INFORMATION OF EMPLOYMENT PRIOR TO DEATH OF THE LATE |
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NAME OF EMPLOYER/ SCHOOL |
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TELEPHONE NUMBER |
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FAX NUMBER |
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ADDRESS OF EMPLOYER/ SCHOOL |
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SECTION 5 |
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INFORMATION ON DEATH OF THE INSURED / LATE |
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DATE OF DEATH |
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CAUSE OF DEATH |
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(Please give full details) |
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INFORMATION OF FUNERAL PARLOUR THAT CONDUCTED THE FUNERAL |
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NAME OF FUNERAL PARLOUR |
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ADDRESS OF PARLOUR |
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CONTACT PERSON AT PARLOUR |
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TEL NO. |
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DATE OF FUNERAL |
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Page 1 of 2
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POLICY NUMBER |
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SECTION 6 |
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INFORMATION OF CLAIMANT |
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SURNAME |
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FULL NAMES |
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ID NUMBER |
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RESIDENTIAL ADDRESS OF CLAIMANT |
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POSTAL ADDRESS OF |
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CLAIMANT |
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POSTAL CODE |
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POSTAL CODE |
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WORK |
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TELEPHONIC AND ELECTRONIC |
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HOME |
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CONTACT INFORMATION |
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CELL |
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RELATION TO LATE |
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OCCUPATION |
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ADDRESS OF EMPLOYER |
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SECTION 7 |
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INFORMATION OF TRIBAL AUTHORITY |
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NAME OF TRIBAL CHIEF / HEADMAN |
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ADDRESS |
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TELEPHONE NUMBER |
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SECTION 8 |
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PAYMENT / ELECTRONIC TRANSER VALIDATION REQUEST |
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NAME OF BANK |
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BRANCH NAME |
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ACCOUNT NUMBER |
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BRANCH CODE |
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ACC HOLDER ID NUMBER |
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ACCOUNT TYPE |
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ACCOUNT HOLDER FULL NAME |
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ACC HOLDER TEL NUMBER |
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SIGNATURE OF CLAIMANT |
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DATE |
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SIGNATURE OF ACC HOLDER |
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DATE |
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SECTION 9 |
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CONSENT TO GAIN ACCESS TO, SHARE AND RECEIVE INFORMATION |
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I, |
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the claimant hereby notify Hollard Life Assurance Company |
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of the death of |
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and state that all the information furnished by me are true and complete. |
A.In the event that this claim or any supporting documents is found to be false and or dishonest, Hollard Life reserves the right to proceed with legal action against me or any other parties involved.
B.It is important for insurance companies to share claims, insurance underwriting and Financial Information in order to enable the fair assessment and underwriting of risks and to reduce the number of insurance fraud.
C.On my behalf and on the behalf of any person I represent herein, I hereby consent to the sharing of private insurance underwriting, financial claims and medical condition information and or records.
D.The information provided in respect of the claim and policy may be verified against other sources of information or databases.
E.I hereby irrevocably authorize any Medical Practitioner, hospital or any other person to disclose and or hand over to Hollard Life, or it’s representatives, any details, records and or documents relating to treatment and or illness, injury or general information relevant to the claim or such information as may be necessary or required to consider this claim.
SIGNATURE OF CLAIMANT
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NAME AND SURNAME |
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WITNESS DETAILS |
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ID NUMBER |
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WORK TEL NUMBER |
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CELL NUMBER |
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SIGNATURE OF WITNESS |
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DATE |
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Page 2 of 2