Claim Application Discharge Hollard Form PDF Details

If you are a claimant who has applied for discharge and been unsuccessful, you can use Form HOLLARD to appeal the decision. This form is used to request a review of the original decision made by the Disability Determination Services (DDS) office. You will need to provide specific information about why you feel that your claim should be discharged, as well as any additional evidence you may have to support your case. The HOLLARD form must be submitted within 60 days of the date on your denial letter. For more information on how to complete and submit this form, please refer to the instructions provided with the form.

QuestionAnswer
Form NameClaim Application Discharge Hollard Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfuneral form for work, burial society membership form, bi 1663 form no download needed, bi 1663 form sample

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CLAIMS APPLICATION & DISCHARGE

HOLLARD FUNERAL PLAN

FAX -

COMPLETED & SIGNED DOCUMENTS TO (011)351-3003

OR

EMAIL -

TO lifeclaimsadmin@hollard.co.za

OR

POST ORIGINALS -

LIFE CLAIMS – PO Box 87428 – Houghton - 2041

 

SECTION 1

VALIDATION AND CONFIRMATION

I,

 

, 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.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2

 

 

CONTRACT INFORMATION

 

 

 

 

 

 

SCHEME NAME

 

 

 

 

 

 

Signature of Claimant

 

POLICY NUMBER

 

 

 

 

 

 

 

 

 

INFORMATION OF THE POLICY HOLDER

 

 

SURNAME

 

 

 

 

 

 

 

 

 

FULL NAMES

 

 

 

 

 

 

 

 

 

ID NUMBER

 

 

 

 

 

 

 

 

 

SECTION 3

 

 

 

INFORMATION OF DECEASED / LATE

 

 

SURNAME

 

 

 

 

 

 

 

 

 

FULL NAMES

 

 

 

 

 

 

 

 

 

ID NUMBER

 

 

 

 

 

 

 

 

 

RESIDENTIAL ADDRESS OF LATE

 

 

 

 

 

POSTAL ADDRESS OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POSTAL CODE

 

 

 

 

 

POSTAL CODE

 

 

 

 

 

 

 

WORK

 

 

 

 

 

 

TELEPHONIC AND ELECTRONIC

 

 

HOME

 

 

 

 

 

 

CONTACT INFORMATION

 

 

CELL

 

 

 

 

 

 

 

 

 

 

EMAIL

 

 

 

 

 

 

SECTION 4

 

 

 

INFORMATION OF EMPLOYMENT PRIOR TO DEATH OF THE LATE

 

 

NAME OF EMPLOYER/ SCHOOL

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

FAX NUMBER

 

 

 

 

 

 

 

 

 

ADDRESS OF EMPLOYER/ SCHOOL

 

 

 

 

 

 

 

 

 

SECTION 5

 

 

 

INFORMATION ON DEATH OF THE INSURED / LATE

 

 

DATE OF DEATH

 

 

 

 

 

 

 

 

 

CAUSE OF DEATH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please give full details)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFORMATION OF FUNERAL PARLOUR THAT CONDUCTED THE FUNERAL

 

 

NAME OF FUNERAL PARLOUR

 

 

 

 

 

 

 

 

 

ADDRESS OF PARLOUR

 

 

 

 

 

 

 

 

 

CONTACT PERSON AT PARLOUR

 

 

 

 

 

 

 

 

 

TEL NO.

 

 

 

 

 

DATE OF FUNERAL

 

 

Page 1 of 2

 

 

 

 

POLICY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 6

 

 

 

INFORMATION OF CLAIMANT

 

 

 

 

 

SURNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FULL NAMES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ID NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENTIAL ADDRESS OF CLAIMANT

 

 

 

 

 

POSTAL ADDRESS OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMANT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POSTAL CODE

 

 

 

 

 

POSTAL CODE

 

 

 

 

 

 

 

 

 

 

 

WORK

 

 

 

 

 

 

 

 

 

TELEPHONIC AND ELECTRONIC

 

 

 

HOME

 

 

 

 

 

 

 

 

 

 

CONTACT INFORMATION

 

 

 

CELL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMAIL

 

 

 

 

 

 

 

 

 

 

RELATION TO LATE

 

 

 

 

 

OCCUPATION

 

 

 

 

 

 

ADDRESS OF EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 7

 

 

 

INFORMATION OF TRIBAL AUTHORITY

 

 

 

 

NAME OF TRIBAL CHIEF / HEADMAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 8

 

 

PAYMENT / ELECTRONIC TRANSER VALIDATION REQUEST

 

 

 

 

 

NAME OF BANK

 

 

 

 

 

BRANCH NAME

 

 

 

 

 

 

 

ACCOUNT NUMBER

 

 

 

 

 

BRANCH CODE

 

 

 

 

 

 

ACC HOLDER ID NUMBER

 

 

 

 

 

ACCOUNT TYPE

 

 

 

 

 

 

ACCOUNT HOLDER FULL NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

ACC HOLDER TEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF CLAIMANT

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF ACC HOLDER

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 9

 

 

CONSENT TO GAIN ACCESS TO, SHARE AND RECEIVE INFORMATION

 

 

 

I,

 

 

 

 

the claimant hereby notify Hollard Life Assurance Company

 

of the death of

 

 

 

 

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

DATE

 

 

 

NAME AND SURNAME

 

 

 

WITNESS DETAILS

 

ID NUMBER

 

 

 

 

 

 

WORK TEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

CELL NUMBER

 

 

 

SIGNATURE OF WITNESS

 

 

 

DATE

 

 

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