GROUP LIFE ASSURANCE GLA AND ACCIDENTAL DEATH CLAIM

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GROUP LIFE ASSURANCE GLA AND ACCIDENTAL DEATH CLAIM Powered By Docstoc
					                                    Underwritten by Regent Life Assurance Company Ltd
                                                 Reg Nr 1994/001332/06

                                     Administered by Health & Accident Underwriting
                                               Managers (Pty) Ltd. – FSP376
                                                PO Box 324, Rivonia 2128
                                     Tel:+27 (0)11 234 7333, Fax:+27 (0)86 573 3972
                                            Email: schemes@healthacc.co.za


                    GROUP LIFE ASSURANCE GLA AND ACCIDENTAL DEATH CLAIM FORM
PERSONAL PARTICULARS OF MEMBER
Surname:
Full Names:
Date of Birth:                                                       ID Number:
Date of Death:                                                       Age at Death:
Cause of Death

PARTICULARS OF MEMBERSHIP
Date of joining the FIA Group Scheme:
Date of Commencement of Membership:

DOCUMENTS ATTACHED
Certified copy of Identity Document                                                                                 YES        NO
Certified copy of Death Certificate                                                                                 YES        NO
Police Report for Accidental Death Claim                                                                            YES        NO

PLEASE NOTE:
THE CLAIM CAN ONLY BE PROCESSED ONCE ALL RELEVANT INFORMATION/DOCUMENTATION HAS BEEN SUBMITTED

BANKING DETAILS FOR PAYMENT OF CLAIM
Name of Bank                       Branch                                                           Branch Code
Type of Account                    Account No
Name & Surname of Account Holder
Signature of Account Holder

DECLARATION AND CERTIFICATION
We, the undersigned, declare that the person mentioned above has died and that the information indicated on this form is complete and
correct.

Signed at                           On the                                       Day of                        Year
                                                ON BEHALF OF THE DECEASED.
                                                          Capacity




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