ABC LIFE
ADDENDUM 2
CASE STUDY 1 DEATH CLAIM CLAIMANT‟S STATEMENT FOR DEATH CLAIM Please complete all questions – do not refer to other documents 1. Life Assured‟s Details a) First Name (s): Hans b) Contract Number (s): 5705187598 c) Occupation: Credit Manager d) Highest Education Qualification attained: Matric e) Postal Address: 5 Cherrywood Street, Fourways f) Residential Address: 5 Cherrywood Street, Fourways g) Date and place of birth: 29.12.1964 - Johannesburg
Surname: Nell
Code: 2055
2. Claimant‟s Personal Details a) a) Your full name: Shirley Nell b) Postal Address: 5 Cherrywood Street, Fourways Code: 2055 c) Date of Birth: 12.02.1966 d) State your relationship to the deceased: Wife e) In what capacity do you claim the assurance benefits? Dependant f) Are you, or have you been insolvent or are any sequestration proceedings pending or contemplated? Yes X No
If “Yes”, please give full details: Contact telephone number: (011) 893-5555 Details regarding the deceased 2.1 2.2 2.3 2.4 Name of assurers, sums assured and date of issue of all assurances held with other companies: None Date, time and place of death: 05.01.2004 Cause of death: Heart disease a) When did the health of the deceased first begin to be affected? Not aware b) When did the deceased first consult a doctor for his/her last illness? 1999 c) Did the deceased smoke tobacco in any form? X Yes No
If “Yes”, approximately how much per day? 15-20 p/d
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ABC LIFE
d)
Is there any reason to believe that the life assured’s death was in any way due to or arose directly or indirectly or, entirely or partially from AIDS or HIV infection? Yes X No
If “Yes”, please give full details: e) X Has the life assured ever been tested for HIV antibodies? Yes No
If “Yes”, what was the result of the test? Negative 2.5 Name and address of every doctor who attended the deceased during his last illness and during the five years preceding his death (need only be completed for contracts with life cover).
Dr Jan Miller, Fourways Medical Rooms, Tel 465-5555, Treated for Bilharzia 2.6 a) Name of deceased’s employer at date of death: African Bank b) Name of deceased’s medical aid society and membership number at time of death: Bankmed - 85968 c) Hospital number: 54879 2.7 Is there any cession or other encumbrance of the owner’s right under the contract? Yes If “Yes”, please give full details: 2.8 a) Has the deceased ever been insolvent, or are any sequestration proceedings pending or contemplated? Yes X No X No
If “Yes”, please give full details: b) Was the estate of the deceased insolvent at the time of death? Yes X No
If “Yes”, please give full details:
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ABC LIFE
2.9
Was the deceased single, married or divorced at the time of death or ever previously married or divorced? State details: Married
Retirement Annuities Only 2.10 a) What dependants survive the deceased? Please supply names, relationship to the deceased and age: b) State the deceased’s income tax reference number and office to which last return was rendered. Payment Details For your protection payment will only be effected by electronic fund transfer: this will also ensure faster payment. Payment may only be made to the owner/nominated beneficiary. No payment to a third party will be allowed. We will require proof of account for example cancelled cheque or bank statement that reflects the account number and name of the account holder. Photostat copies or faxed copies are not acceptable. Name of Account Holder: Shirley Nell Name of Bank: Nedbank Branch Code: 13585600 Account Number: 5698755789559 Name of Branch: Albert Street Account Type: Cheque
It is most important to give the correct account number, name and spelling of the account to be credited. ABC Life will not bear any responsibility for delays or other damage due to incorrect details being provided. Death Claim Declaration (Legal Guardian to sign for minors) I, Shirley Nell, the claimant, hereby make claim to the benefits of the above assurance contract/s and declare that the aforegoing answers and statements are true to the best of my knowledge and belief, and that I have withheld no material fact from ABC Life. I agree that the written statements and affidavits of all papers submitted in support of this claim shall constitute and are hereby made a part of this claim. I further agree that the supply of this form or of any other forms supplemental hereto by ABC Life shall not constitute an admission that there was any assurance in force on the life in question or a waiver of an of its rights or defence in law. I acknowledge and agree that any benefits payable in respect of this claim shall be forfeited if I, or anyone acting on my behalf or with my knowledge and consent, have knowingly withheld any material fact or submitted any false information in respect of the claim.
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ABC LIFE
I further agree that upon payment by ABC Life of the benefits hereby claimed, ABC Life shall be discharged from all liability in respect of such benefits. Signed at: ……………………………. this ………………… day of …………………………
Claimant’s Signature: ……………………………….
Witness: ……………………..
POLICY NUMBER – 5705187598
CONTRACT SCHEDULE Owner: Mr Hans Nell Life Assured: Mr Hans Nell Date of Birth: 29.12.1964 Commencement Date: 01.07.1992 Benefits: Basic Life Cover: Living Lifestyle: Guarantee Review Date: Options: Total Contribution: Investment Avenue: Intermediary: Date Issued: Assured Amount R150 000,00 Cease Date 05.01.2004
01.07.2018 Automatic benefit increase – 6% R100.00 per month Managed Portfolio BDY Insurance Brokers 10 September 1992
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ABC LIFE
STATEMENT OF CONTRACT
ABC Life undertakes to provide the benefits described in the Schedule of Benefits subject to the conditions stated in this contract. This contract of assurance consists of the Application Form and all other supporting documents and the Schedules and Annexures hereto. Where a date of birth is noted as ”not verified” documentary proof of age should be submitted to ABC Life as soon as convenient. Such proof is required before any benefit can be paid under this contract.
Signed at Johannesburg on 10 September 1992 (Issue Date) Checked: …………………………. Authorised Official …………………
Duty Paid R75.50 DECLARATION OF DEPENDANCY To enable the Trustee of the fund to consider payment to a dependant in equitable proportions should the claim be admitted, we require the Executor of the Estate or the surviving spouse to provide the following information: Estate Late: Hans Nell Contract Nd: 5705187598
1. Was the deceased married at the date of death? X Yes No
Spouse’s Full Name: Shirley Nell Date of Birth: 12.02.1966
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2. Children of deceased from present marriage/previous marriage(s). adoption: Full Name and Surname Date of Birth Was the child financially dependent on the deceased? Yes Yes Yes 2.1 2.2 If financially dependent, please substantiate: Please supply full names of the guardian of any minor child (foster parents do not necessarily qualify as guardians): Full Name and Surname N/A Date of Birth Child‟s Name No No No
3.
Was the deceased previously married? Yes X No
Details of Ex-Spouse(s): Full Name and Surname Date of Birth
If the previous spouse (s) received maintenance from the deceased, please specify amount and provide a certified copy of divorce a) Amount in respect of b) Amount in respect of children: 4. Name of any other person in fact financially dependent upon the member at the time of his/her death and any other person in respect of whom the member would have become legally obliged to maintain if the member has not died, for example, an unborn child.
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ABC LIFE
Full Name and Surname N/A
Date of Birth
Relationship to Member
5. Name Inheritance
I clarify that the information furnished above is to the best of my knowledge and belief true, correct and complete. Surviving Spouse Name: Shirley Nell Address: 5 Cherrywood Street, Fourways Tel No:011 893-5555 Signed: Date: 12.01.2004 Or Executor Name: Address: Tel No: Signed: Date:
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ABC LIFE
DEATH CLAIM ASSESSMENT Life Assured: Date of Birth: Mr Hans Nell 29.12.1964 BTM No.:
Payee/Relationship: Mrs Shirley Nell
Contract Number 5705187598 Req Requirements Years in Force 1.7.1992 Date Rec Req
User ID:
Image Called Yes If Retirement Annuity Additional requirements as follows: Marriage Certificate Proof of Age of Beneficiary List of Dependants from Executor Tax Directive - 13789 Election and Discharge Form Date Rec
X
Death Certificate Claimants Statement Medical Statement from Dr Post Mortem Full Inquest Statement by Police
12.01.2004 12.01.2004 X
15.01.2004 25.01.2004
X
Proof of Account Date Req
12.01.2004 Date Rec
Additional Req
None
Assessor‟s Decision Assessor‟s comments Name:
Accepted Pay full amount Signed Date
Checked by: D Connell
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ABC LIFE
POLICY
EMPLOYER
PREMIUM HISTORY Status Processed Member No 546 Middle name Schalk Member status Active Surname Nell Commencem ent date 01.07.1992 Product Whole Life Prototype Lifestyle Protector 1
Policy No 1246787 Name: Prefix Mr Birth date 29.12.1964 Retirement age 65 Salary 50 000 Sex Male
First name Hans Marital status Married Evidence Received Premium 100.00
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ABC LIFE
PAYMENT DETAILS Request no Payment no Payment method Authority Status Reference no Payee name Payee ID no Payee Address 56075 1 EFT Fully 5 1246787 Shirley Nell 6412291560 86 1 Willow Rd Mondeor 2195 Payment date Status date Payment user Payment Amount Proc date Group no. Payee Acc Branch code 01.06.2004 01.06.2004 PRM0602 150000.00 15.06.2004 6875 620014789 21021443 Payment system Language code Cheque no Related policy no Reason PMS 1 N/A None 105 ERBPMT: Death Claim
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ABC LIFE
Letter confirming payment
Ms S Nell Profin Brokers (Pty) Ltd PO Box 689 Johannesburg 2000 Dear Madam Contract number 5705187598 in name of the late Hans Nell We confirm that full and final settlement R R150 000.00 has been made in respect of the above policy. The amount was paid into: Bank: Branch: Account Number: Nedbank Albert Street 5698755789559
In the event of any queries, please contact your administrator on (011) 555-5556. Yours faithfully D Connell Claims Administrator ABC Life
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ABC LIFE
CASE STUDY 2 – DISABILITY CLAIM Claimant‟s Statement of Disability Claim To be used when claiming for Lump Sum Disability (OOD/OD/TD), LIP/IPP, Disability Premium Waiver (ODCW), and Continuous Disability The contact person for the claim is: Name: B. Smith E-mail address: b.smith@abclife.co.za Tel No: 555-5158 Branch: HO Cell No: 082 518 4117 Fax No:
NB: Claims Department will send correspondence and copies only where this information has been supplied in other circumstances: correspondence will be directed to the Owner/Life Assured. 1. Claimant details: a) a) Policy Number (s): 5556669 b) Name of Claimant Surname: Grobler First Name: Marie Initials: M c) Date of Birth: 02.02.1954 Identity Number: 5402020115081 d) Name of Medical Scheme: Synthesis Medcare Scheme Number: 5897456 e) Residential Address: f) Postal Address: g) Telephone Number: (H) Fax Number: (W) Fax Number: E-mail address: Cell Number: h) What is the highest academic professional or trade qualifications? Nursing sister f) i) Personal Status (please tick appropriate block): Married X Single Divorced Widow/Widower
j)
If married, please state occupation of spouse: Car Salesman Are you or the Life Assured or have you or the Life Assured ever been insolvent or is any sequestration proceeding, pending or contemplated? Yes If yes, please provide details: X No
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ABC LIFE
2.
Particulars of present occupation (also applicable to self employed): a) Name and address of last/present employer: Mediclinic, 100 Victoria Rd , Alberton b) Length of service with employer: 23 years c) What was your full-time occupation immediately before your current disability/ impairment began? Nurse d) Breakdown your duties: Administrative% 45% e) Supervisory% 30% Manual% 20% Travel% 5%
f) g)
Give an accurate description of the exact duties and nature of your full -time occupation (job description): Consultation with patients, dispensing medicines, administering vaccines, supervision of junior nurses. Is the aforementioned your nominated occupation and if yes how long have you been following this occupation? 23 years State particulars of any hobbies or other occupations: None
Please note that in the event of any modification or variation of this standard form, ABC Life will regard this form as being invalid and of no force and effect. h) Occupations held in the past 10 years. Nature of Occupation and Employer Mediclinic Date From 1981 To 2004 Date
i)
On what date were you last able to undertake any part of the duties of your occupation? 30.9.2002 When do you expect to return to work? Unable to do so Have you been offered or enquired about any alternative occupation for remuneration by your Employer? Yes X No
j) k)
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If “Yes”, describe duties of alternative occupation offered: Have you accepted the alternate occupation offered? If “Yes”, when do you expect to follow the alternative occupation? On a full time basis: What is your expected remuneration? 3. a) Are you a smoker? Yes If “Yes” ,how many per day? b) Do you consume alcohol? Yes X No X No On a part time basis:
If “Yes”, what do you drink and the quantity consumed? 4. Information relating to your impairment a) Nature of disability/impairment(s): Vertigo and poor vision b) Indicate whether your impairment (s)/disability is due to (please tick the correct block): Accident trauma c) Disease/illness X
If the disability/impairment is a result of an accident, when, where, and how did the accident occur? Please furnish details of the relevant case number and the details of the police station at which the accident was reported: Have you instituted any clam for benefits against the Multilateral Motor Vehicle Fund? If “Yes”, please provide us with a reference number under which the claim was lodged:
d)
If the disability/impairment is due to illness/disease ,please provide the following details: Date when the illness/disease was first diagnosed: January 2000 Names and addresses of all attending doctors: Dr N Bhaga, Dr Nana
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ABC LIFE
What prescribed treatment are you currently taking/using? Stugeron – 25mg dinil 5mg,Metformin – 500g, All: 3 x daily Name and address of your usual doctor during last six years: Dr Jacobs, 35 Lange Rd ,Alberton Have you been confined to bed/house/hospital? Now confined to house For how long? Permanently History of all medical consultations/treatment over last five years (treatments for flu and colds may be omitted): Dates 20.06.1999 02.02.2001 Reasons Vertigo Recurring vertigo Recurring vertigo Recurring vertigo Treatment Cinnarazinne Drugs and postural exercises Drugs and postural exercises Drugs and postural exercises Cinnarazinne Hospital/ Doctor Dr Nana Dr Nana Telephone Number
11.05.2001
Dr Nana
01.02.2001
Dr Nana
Dr Nana 20.06.1999 5. Vertigo
Information relating to your Income, ABC Life to call for proof of income and sight of relevant tax forms): 5.1 a) b) 5.2 What was your taxable income for the past 12 months? R 120 000 Commission earned during the past 12 months: None Directors fees for the past 12 months: None a) Have you received any income since disablement? If “Yes” please state income amount for every month since disablement: Yes X No
b) Please provide details of the source of income:
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ABC LIFE
5.3
a)
Have you lodged or do you intend lodging a claim for payment of disability benefits with any other insurance companies? If “Yes” please furnish us with details: No Policy Number 5556669 Date of Inception Estimated Value R350 000
Name of Insurance Co. ABC Life
b)
Are you currently receiving any other benefits to supplement your income during your disability? Yes No
6.
Payment Details For your protection, payment will only be effected by electronic fund transfer, this will also ensure faster payment. No payment to a third party will be allowed. Payment may only be made to the owner. Payment will be made to the bank account that is currently paying the premiums. If payment is to be made to a different account, we will require proof thereof for example cancelled cheque or bank statement that reflects the account number and name of the account holder. Name of Account Holder: M Grobler Name of Bank: Nedbank Branch Code: 020568 Account Number: 525896358
Name of Branch: Alberton Account Type: current
It is most important to give the correct account number, name and spelling of the account to be credited. ABC Life will not bear any responsibility for delays or other damage due to incorrect details being provided. Please note that in the event of any modification or variation of this standard form, ABC Life will regard this form as being invalid and of no force and effect.
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ABC LIFE
Go Life Contract – Policy Number 555669 Please read this document carefully as it contains important information that you need to consider before applying for the product concerned. The information provided is a summary of the main features of the product and does not constitute an offer by ABC Life. You may be asked to sign this document – your signature is simply proof of receipt and is not an acceptance of the contents of this document. Prepared for : Date of Commencement: Contribution Type: Annual Benefit Increase: Mrs M Grobler 01.10.1993 Age Rated 7% p.a. Contribution Frequency: Monthly Annual Contribution Increase: This will increase each year with age. Prepared by: B Brite
1. Details of the Lives Assured Principal Life Name Date of Birth Age next birthday Gender Smoker Status Educational Qualification Annual Income Rating Category Occupation Percentage Duties M Grobler 02.02.1954 41 Female Non-smoker Nursing Degree 48000.00 1 Nursing Assistant Admin 20% Manual 80% Travel 0% Occupation Category 3
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ABC LIFE
2. Benefit and Contribution Details Principal Life's Benefits Life Protection Life Cover Go Life Disability Capital Disability (OD) Go Life Dread Disease Go Life 65) Policy Protection Premium Protector - Disability Total Contribution for Principal Life's Benefits Monthly Policy Fee Total Monthly Contribution 15.00 206.24 Contract anniversary preceding age 65 13.84 191.24 400,000 Contract anniversary preceding age 65 29.60 300 000,000 Contract anniversary preceding age 65 40.80 1,000,000 Whole of Life 107.00 Benefit Amount Benefit Term/Cease Age Initial Monthly Contribution
Notes: Contributions are guaranteed for an initial period of 10 years. Where the benefits have a term shorter than 10 years, contributions for that benefit are guaranteed for the term. Contributions for the Principal Life's Benefits on the contract are guaranteed not to increase by more than 25% at the end of the initial guaranteed period. These contributions will be guaranteed for a further 10 years.
Failure to accept any recommended increases in contributions will result in the benefits reducing to an appropriate level for the contribution paid at the review date.
Loadings and/or benefit contributions will discontinue after the specified cease dates.
Any application will be subject to ABC Life`s acceptance procedures.
The contributions are subject to certain minima. If in doubt please discuss these with your financial adviser.
Guaranteed values and contributions as set out in this document are calculated on the assumption that all contributions are paid in accordance with the provisions of this contract.
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ABC LIFE
Contributions can be paid monthly or annually. Monthly contributions can only be made by way of debit order. Annual contributions can be effected by debit order or by cash deposited directly into ABC Life`s bank account, using a M65 form. This can be obtained by calling our call centre or your Financial Adviser.
Note that if the contribution remains unpaid for a period of 30 days, the contract will lapse.
Charges and Fees:
Commission payable to intermediaries is currently regulated by law. This amount is not deducted directly from your contributions, but is recovered from the contract charges set out above over the term of the contract.
The standard Commission payable to an independent financial adviser for this contract is R1,998.43 in the first year and R666.06 in the second year.
If an Automatic Contribution Increase is applicable to this product, a proportional amount of commission will also be payable annually in respect of the increased contribution.
If your Financial Adviser is a representative of ABC Life, the amount of the commission payable will differ as he/ she may receive other benefits not directly related to this contract.
Commission amounts reflected exclude Vat.
3. Product Description Go Life Product is a whole of life costed contract, which provides no cash values on surrender other than where the Financial Protector Benefit is selected. The product caters for an option to select a Family Plan structure and the choice of different contribution types. Accelerated and NonAccelerated benefits are offered, and there is no requirement to select life cover under the contract.
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4. Benefit Descriptions Accelerated Benefits Claims paid out under accelerated benefits reduce the level of life cover by the amount of the claim paid. The level of cover enjoyed under any other accelerated benefit may also be affected.
Age Rated Contribution The contributions under this contribution type increase each year based on the contract holder`s age next birthday and benefit level.
Annual Benefit Increase On each contract anniversary, the benefits will increase at the selected rate where applicable. 5. Life Protection Life Cover If the Principal life assured dies before the cover cease date, the applicable life cover amount will be paid as a lump sum. Should either of the lives assured be diagnosed with a terminal illness, which in the opinion of ABC Life’s Chief Medical Officer will result in death within 12 months of diagnosis, a Terminal Illness Benefit equal to 85% of the Sum Assured can be paid out in lieu of the Death Benefit. 6. Go Life disability Capital Disability (OD) This is an accelerated benefit. A state of disability exists if, as a result of injury, disease, or surgical operation, the Principal life assured is and has been for a period of 3 consecutive calendar months, totally and permanently incapable of earning an income from his/her own occupation, a reasonable occupation or any other occupation, they could reasonably pursue, taking into account their knowledge, training working experience and ability. 7. Lifestyle Protection Go Life Product Benefit A benefit providing an accelerated payment of all or part of the life cover in the event of the diagnosis of defined dread disease conditions.
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8. Policy Protection Premium Protector – Disability A benefit providing for the waiver of contributions in the event of the life assured being totally incapable of performing the duties of his/her nominated occupation or any other occupation that they could reasonably pursue, through disease or bodily injury or surgical procedures. 9. Important Notes and Information Validity of Information Reference Number: 555669 Smoker Status and Annual Income Benefits are based on the Smoker Status and Annual Income specified for the Lives Assured. If the specified information is incorrect, benefits will be adjusted appropriately in accordance with the terms and conditions of the contract. Insolvency If the owner is an un-rehabilitated insolvent, the owner’s trustee must consent in writing to any contract arising from this document. If the Life Assured is an un-rehabilitated insolvent and has not disclosed his status, ABC Life reserves the right to restrict the benefits in accordance with its business practice from time to time. Claim Notification procedures If you wish to claim on your contract, please contact your financial adviser for the required documentation or you can telephone our Call Centre, on 0860 456 789.
Compliance and Complaints Should you have any queries or complaints regarding your contract, please first contact your financial adviser and discuss the problem with him/her. If the matter is not handled to your satisfaction, you can contact the ABC Life Policyholder Relations Department on telephone (011) 555-8888 . In the event that the dispute is still not resolved to your satisfaction, you may refer any dispute to the:
Ombudsman for Long Term Insurance Private Bag X45 CLAREMONT 7735 Tel: (021) 657-5000 Toll free: 086 010 3236 Fax: (021) 674-0951
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Or Registrar for Long Term Insurance Financial Services Board PO Box 35655 MENLO PARK 0102 Tel: (012) 428-8000 Fax: (012) 347-0221
Or FAIS Ombud Mr Charles Pillai Financial Services Board PO Box 35655 MENLO PARK 0102 Tel: (012) 428-8000 Toll free: 080 0110443 Fax: (012) 347-0221
Underwriting Please note that your contract is subject to ABC Life’s underwriting procedures and if any loadings or exclusions are imposed which alter the information provided in this document, you will receive revised information from us, prior to issue of your contract.
If you have agreed to accept an initial loading, note further that, if this loading is imposed, it will change some of the information contained in this document and the revised information will be sent to you with your contract document. Please ensure that you read these changes carefully, as they will form the basis upon which your contract will be issued.
Replacement Information You may not be advised to cancel a contract to enable you to purchase a new contract or amend an existing contract, unless: (a) The intermediary identifies the contract as a replacement contract. (b) The implications of cancellation of the contract are disclosed to you, such as: The influence on your benefits under the old contract.
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The additional costs incurred with the replacement. The insurer that issued the original contract may contact you. You are advised to discuss the matter with its representative.
Exclusions and Waiting Periods. Certain insured events may be subject to waiting periods and others may be specifically excluded. The details of these periods and exclusions will be contained in your contract document.
Please ensure that the above implications are fully explained to you either by your financial adviser or by calling our Call Centre on 086 0456 789. Cooling Off. If, after purchasing this contract, you find that it does not meet your needs, you are able to withdraw from it at any time within 30 days of the date on which you receive details of the issued contract, provided you have not yet claimed under the contract or the event insured against has not yet occurred. If you decide to withdraw, ABC Life is entitled to deduct an amount in respect of any cover you may have enjoyed or in respect of any decrease in investment value of your investment, before returning your contributions to you, but will make no further deductions in respect of charges or expenses. Presented by: B Brite Jet System Contract
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Employer‟s Declaration If self employed, to be completed by audit or bookkeeper or relevant third party Contract Number: 5556669 Full name of Employee: Mediclinic Employer Number: 5869 1. a) b) a) b) a) b) c) d) Date of Birth: 02.02.54 ID Number: 5402020115081
Name of Company: Mediclinic Fax Number: E-mail address: s.black@mediclinic.co.za Tel. Number: 555-6689 Medical Aid Scheme: Synthesis Medcare Membership Number: 5897456 Initial Date of Employment: 1.10.1980 On what date was the employee last able to undertake any part of his/her occupational duties at work? 24.09.02 On what date was the employee’s service terminated? Boarding in process Reason for termination (for example ill health, retirement /retrenched /boarded ), (If the reason for termination relates to boarding, please attach the relevant documents): Boarding due to chronic vertigo. Until what date has any remuneration been paid? On sick leave – to be paid until fully boarded Was the employee then in full -time or part-time employment? Full time
2.
3.
e) f) 4. 5.
What was the employee’s designated occupation? Nurse What was the exact nature of the employee’s work (please give full details or attach a copy of job description):?Taking care of patients, administering medication, visiting clinics, supervising clinic staff Anticipated date that the employee will return to work (if applicable): Unknown Has any consideration been given to the extent to which the employee’s work circumstances or duties might be adapted to accommodate the employee’s disability needs? If “No”, furnish reasons: X Yes No
6. 7.
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8.
Has any consideration been given to the availability of any other suitable work? If “No” furnish reasons: X Yes No
9.
In the event of being self -employed, please state if business is to continue. If “No” ,state reason why: Yes No
10.
Other insurances a) Have you been approached by any other insurance companies for information relating to the employee’s current state of disability? If “Yes”, please provide details of the name of the insurer and the relevant policy number(s) if in your possession: Yes X No
b) Is the employee entitled to other disability benefits (for example, benefits from a pension fund, group life ) If “Yes” ,please provide the relevant details: X Yes Municipal Pension Fund No
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Name:
M Grobler
Policy Number: 5556669
Declaration I hereby warrant and declare that the foregoing answers and statements are true to the best of my knowledge and belief, and that I have no material fact from ABC Life. I further declare that the condition giving rise to this claim was not due in any way to self inflicted injury or use of alcohol or drugs of any kind and that I am not insolvent. I agree that the written statements and affidavits of all the doctors who attended or treated the Life Assured and all other papers submitted in support of this claim shall constitute and are hereby made a part of this claim, and further agree that the supply of this form supplemental hereto by shall not constitute an admission by it that there is any assurance in force on the life in question or a waiver of any of its rights or defences in law. I acknowledge and agree that any benefits payable in respect of this claim shall be forfeited if I, or anyone acting on my behalf or with my knowledge or consent, have knowingly withheld any material fact or submitted any false information in respect of this claim. I further agree that upon payment of the benefits hereby claimed. ABC Life shall be discharged from all liability in respect of such benefit. I hereby authorise any medical practitioner, hospital or any other person to furnish to or its representative any details relating to any illness or injury to the Life Assured or such information as may be necessary to consider this claim. I know and understand the confidential nature of medical information. By appending my signatures at the end of this Personal Declaration. I am agreeing that I have given permission to ABC Life to obtain medical information and evidence from and/or through third parties without it being seen as a breach of my right to privacy and confidentiality. I further agree that any authorised medical personnel or practitioner may release confidential information to ABC Life or other person acting on their behalf and in such manner or method as may direct. I indemnify ABC Life and its directors, agents and employees against any claim of whatever nature which may be made against them as a result of or arising out of the furnishing of such information. Where the conditions of the contract so allow. I irrevocably authorise ABC Life to deduct any expenses incurred by it in respect of this claim and for which I am liable from the benefits payable under the contract. Signed at: Owner’s Signature: Life Assured’s Signature: this Witness: Witness: day of
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Medical Certificate for Disability
To Dr: M Nana Address: NHD Medical Rooms 44 Main Road Rosettenville Doctor‟s Details Name of Doctor: M. Nana Address: NHD Medical Rooms 44 Main Road Rosettenville Telephone Number: 555-6666 E-mail Address:
Patient/Claimant Details Name: Marie Grobler Policy Number: 5556669 Date of Birth: 02.02.1954
Practice Number: 58794 Facsimile Number: 555-6667 Qualifications: MD
I declare that 10 of the best of my belief and knowledge, the information contained in this report is true, accurate and complete and that any information that could influence a decision regarding this claim, has been withheld. Signature of Doctor: Date of Report: Please supply the following details in order for us to pay your account: Name of Bank: Account Number: Confidential Notice This information is intended for the addressee only and may contain confidential and privileged information. If you are not the addressee, the employee, or agent thereof, you must not take any action based on the information enclosed. If this facsimile is received in error, please notify the sender immediately to arrange return at our expense. Dear Doctor We would appreciate your co-operation in providing the information requested in this form.
Branch Code:
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Insurance disability has two components, that is, functional impairment and disability. The assessment of functional impairment rests with various medical experts and is aimed at establishing his degree of impairment of normal functions due to medical, psychiatric, or traumatic causes after reasonable treatment. It also involves the duration of the impairment, whether it is of a permanent nature or temporary, and, if temporary, the likely duration a prognosis. The decision regarding disability is a legal decision taken by the insurance company and is based on details of the claimant, the occupation for which the claimant is insured, the terms and conditions on which the risk was accepted and the policy issued, and the medical impairment of the life assured itself. The information requested, is, therefore, required to assist us in reaching this decision as quickly as possible. The fee payable is in accordance with the scale agreed by the Life Offices’ Association and the Medical Association of South Africa (tariff 1.1.2 or 2.1 as applicable). Please do not hesitate to contact us if you require further information. Thanking you in anticipation.
Yours faithfully
Please note that in the event of any modification or variation of this standard form, ABC Life will regard this form as being invalid and of no force and effect.
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Name:
Marie Grobler
Policy Number: 5556669
Claimants‟ Details: Full Name of Claimant: Marie Grobler Date of Birth: 02.02.1954 ID Number :5402020115081 Telephone Number: 581-5555 Occupation (including description of duties): Nurse Qualification: Nursing sister Medical History 1. 2. 3. 4. 5. 6. Date 20.06.1999 02.02.2001 11.05.2001 01.02.2001 Diagnosis and reason for claim: Chronic vertigo with permanent disability Date symptoms started: 1999 Date first seen by doctor for this reason: 24.06.1999 Date stopped work: 30.09.2002 Date expected to return to work: Now boarded Date seen by you for any other conditions (please give dates and details below): Reason for Consultation Vertigo Recurring vertigo Recurring vertigo Recurring vertigo Treatment Prescribed Cinnarazinne Drugs and postural exercises Drugs and postural exercises Drugs and postural exercises Duration of Complaint Months Months Months Months
Policy Number: 5556669 Facsimile Number:
Last Day at Work:
Medical References Please give the details of any other Practitioner, Specialists or Hospitals to whom the claimant has been referred. Please include copies of all available specialists’ reports. Name of Practitioner/Hospital Speciality Postal Address Complaints Referred for Dr N Bhaga Dr Donald Neurology Eye Specialist 801 Maxwell Centre , Mediclinic, Alberton JHB Vertigo Poor vision
74
ABC LIFE
Name: Medical History
M Grobler
Policy Number: 5556669
Please give full medical history including the following: Symptoms and diagnosis Dates of any diagnoses Clinical details indicating severity and permanence Relevant test results (for example, lung function readings, X-ray or scan results) Treatment and responses Other comments
Severe recurring Vertigo since 1999. Disabling to the extent that medically boarded since 2003. Also suffering from Diabetes Mellitus and impaired vision.
Current major complaint (s): Chronic Vertigo
Results of most recent Medical Examination Date of Examination: 17.02.2004 Please give full clinical details as at that examination, including height, weight and blood pressure readings. Please include details of any limitations evident at that examination (for example joint limitations, visual acuities): Height: 1.5m Weight: 80 kg BP: 120/80 Chest clear
Prognosis: Chronic Vertigo What are chances of recover (good/fair/poor/nil)? Poor Are any residual problems likely? Please specify:
Date expected to return to work: Not expected to return The intentional consumption of alcohol, narcotics, or any toxic substances If “Yes” .please provides details:
75
Yes
X
No
ABC LIFE
Is current medical impairment due to? a) previous illness or injury? b) the intentional consumption of alcohol, narcotics, or any toxic substance? c) attempted suicide or any self -inflicted injury? Yes Yes Yes X X X No No No
Please note that in the event of any modification or variation of this standard form, ABC Life will regard this form as being invalid and of no force and effect.
76
ABC LIFE
Name:
M Grobler
Policy Number: 5556669
Functional Abilities Please comment on the member’s ability to carry out the specified activities in the table below:
Activity Current Limitations No Limitation Seated/sedentar y tasks Clerical/adminis trative tasks Thinking clearly and making decisions Interacting with other Walking (nonstrenuous) over level ground Walking (strenuous) over uneven ground Climbing Kneeling Standing Bending Operating light machinery Operating heavy machinery Working with light weights Driving a light motor vehicle Driving a heavy motor vehicle Light manual labour Use of both arms and legs Use of coordination Working in cramped conditions 77 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X Partial Limitation X Impossible Expected Future Ability Danger to self or others Improve Remain Constant X Deteriorate
ABC LIFE
Working in a dusty environment Working in a fume environment
X
X
X
X
General comments which may clarify the responses in the table. If improvement is expected, please indicate the time period in which that improvement is anticipated. If period off work longer than usually expected of impairment, please give reason:
Treatment and Rehabilitation Current medication regime. Please specify all medications and dosages: See Script
Other treatment the claimant has received or is currently receiving (for example physiotherapy, occupational therapy, psychotherapy): Postural exercises
Please note that in the event of any modification or variation of this standard form, ABC Life will regard this form as being invalid and of no force and effect.
78
ABC LIFE
Name: Planned future treatment, including surgery:
Policy Number:
No surgery planned – continue regular medication for diabetes and vertigo. Avoid driving, working near machinery.
Your recommendations regarding rehabilitation (if applicable): Regular hospitalisation, exercises may be of benefit
Please attach copies of any correspondence received from any practitioners, Specialists, or Hospitals in respects of the claimant.
79
ABC LIFE
DISABILITY ASSESSMENT Life Assured: M Grobler Date of Birth: 02.02.1954 BTM No: 5874 User ID: bb567
Contract Number 5556669
Benefit Disability
Comm Date 01.10.1993
Status In force
Image Called Yes
U.W Decision
Req
Requirements
Date Rec 01.02.04 01.02.04
Req
If dread disease, additional requirements as follows Heart Attack: Cardiac Enzyme Report and ECG Coronary Artery Surgery: Angiogram and Surgeon’s Report Stroke: Neurologist’s Report Cancer: Histology Report
Date Rec
Claimant’s Statement x Medical Statement from x PMA Report Applied for from Dr Proof of Account x Employer’s Declaration
01.02.04
Kidney Failure / Paraplegia / Major Organ Transplant /Blindness/ Major Burns / Coma/Aids/ Multiple Sclerosis: Relevant Specialist’s Report
Additional Requirements
Date Req 11.02.04
Date Rec
Tax directive requested
80
ABC LIFE
Released
Amount R300 000
Request No. 5268
Date Authorised 30.02.2004 Accepted B Colt
Date 03.03.2004
81
ABC LIFE
CASE STUDY 3 - MATURITY CLAIM Application for a cash withdrawal Cash value Risk fund value Optional cash value Debt settlement Optional maturity value Voluntary purchase annuity/lump sum investment plan
Section A: Personal and policy benefit details The policyholder must fill in this section Policy number: 987654 Policyholder (full names: Sandra Francis
Postal Address: 5 Juniper Road Street, Northcliff Postal Code: 2195 Title (e.g. Dr/Prof/Mr/Mrs) Mrs RSA ID: 5005150118086 Telephone: work: 636-5255 Gender: Female Telephone: home: 678 -1212l
Additional Policyholders: 1. N/A 2. ……………………………………………………………………………….
Insured Life if other than policyholder Policy number: …………………………………………….
Policyholder (full names): …………………………………………………….. Postal Address: …………………………………………………………………. …………………………………………………………………. ……………………………………………………………..Postal Code: ………… Title (e.g. Dr/Prof/Mr/Mrs) Gender:
82
ABC LIFE
Male RSA ID: ………………………………………………… Telephone: work: ……………….. ……………………….………. Telephone: home: ………………. …………………………….. Cell number: …………………….. …………………………………….. Fax - Work: Fax – Home: E-mail:
Female
Cessionary: …………………………………………………………………………………………………………… ……………………………………………………………………………………………………………
83
ABC LIFE
Additional cessionaries: 1. 2.
Section B: Options a. Cash value Please indicate your choice with an “x” 1.1 Cash value (cancel the policy) 1.2 Cash value (cancel the pure endowment rider savings benefit and continue the policy) The reason I no longer need this policy is: Policy matured If a new application replaces this policy please state the insurance company: N/A Optional Cash value:N/A Debt settlement: N/A Do you require a quotation Yes Amount required: R 70267.93 Debt amount to be settled: No X X
Signature
Date
Section C: Banking Details The government recently implemented the Financial Intelligence Centre Act (FICA). Section 21 of the Act stipulates that ABC Life must fully identify a third party before entering into a transaction with such an entity. As a result, we decided that our company will not allow third party payments. Pay the applicable value into my banking account Name of institution Branch Type of Account Account number Bank Branch code Standard Bank Braamfontein Current Account 52847859 005805
84
ABC LIFE
Please provide us with a copy of your complete bank statement or a cancelled cheque as confirmation of your banking details. Signature of Policyholder:……………………………… Date:…………………………………………….
85
ABC LIFE
Section D: Declaration I/we warrant that: 1. 2. 3. 4. I am/we are the legal owners of the policy or benefit and competent to deal with the proceeds thereof My/our estate/s is/are solvent and has/have never been surrendered or sequestrated. I/we have not ceded or pledged the policy or benefit to anyone either by antenuptial contract or otherwise except for a loan on the policy or benefit I/we specifically authorise ABC Life to pay the proceeds to me/us into the account indicated and I indemnify ABC Life against all actions, suits, claims, demands, costs and expenses resulting from ABC Life giving effect to my/our instruction to ABC Life. I/we warrant that I/we am/are the legal owners of the policy or benefit and entitled to deal with it. I/we indemnify ABC Life against all actions, suits, claims, demands, costs and expenses against ABC Life by any third party with more claims to ownership than me/us in relation to the policy or benefit. If I/we have selected options 1 in Section B, I/we cede, subject to existing conditions of the policy, all my/our major rights, title and interest under the policy to ABC Life in consideration for which I/we accept payment of the cash value from ABC Life. I/we acknowledge that ABC Life or its legal successors, may have access to my personal information contained in the policy. I/we accept that any money, plus interest, is payable to me/us. ABC Life will determine the interest rate in accordance with the policy at the time.
5.
6.
7.
Signed at:………………………………………………..Date:…………………………………….
………………………………………………….. 1. Signature of policyholder/duly authorised person signing on behalf of the policyholder where the policyholder is not a natural person
---------------------------------------------------------------------------------------------------------------------------
86
ABC LIFE
GO LIFE Investment Selection with Multiple Choice Contract number: 987654 SCHEDULE
The annuity contract is linked to a life policy, which is issued automatically free of evidence of health. Each contract consists of this Schedule, the terms and conditions contained herein, the application for the contract, and all information received in support of the application. Annuitant/Life Assured: Nominated Beneficiary: Commencement Date: Purchase Price: First Annuity Instalment Date: Initial Annuity Instalment: Selected Income Level: Investment Method: Date Issued: Mrs Sandra Francis Mr B. Francis 01.09.1998 R70 267.96 22.01.2003 R3 364.69 5% See below. 1.02.2002
PORTFOLIOS
ALLOCATION AMOUNT R
INVESTMENT PERFORMANCE GUARANTEE ON THE 10TH CONTRACT ANNIVERSARY AND ON EACH 5TH ANNIVERSARY THEREAFTER
L S Property CPI Ermitage Asset Select Total Allocation Amount
33 904.28 337 28.61 676 32.89
The Consumer Price Index (CPI) as published by the Central Statistical Services for the twelve-month period ending three months prior to the contract anniversary.
87
ABC LIFE
TERMS AND CONDITIONS 1. ANNUITY INSTALMENTS Annuity Instalments are payable to the Annuitant, provided ABC LIFE receives satisfactory proof, on request, of the continued existence of the Annuitant. Annuity instalments are payable, after deduction of any required tax and the monthly contribution in respect of the life policy, throughout the lifetime of the Annuitant. The monthly contribution in respect of the life policy is reviewable on each contract anniversary. The initial annuity instalment is payable during the first contract year. On each contract anniversary, the annuity instalment amount is recalculated by multiplying the value of the investment account by the selected income level, and dividing the amount calculated by the number of annuity instalments payable in the forthcoming contract year. Subject to ABC LIFE’s practice and requirements at the time, the Annuitant may change the selected income level on any contract anniversary. One month’s written notice is required. On death of the Annuitant, no further annuity instalments are payable in respect of the annuity contract. 2. INVESTMENT ACCOUNT ABC LIFE will operate an investment account for this contract. The investment account will be credited with the total allocation amount as shown in the schedule. The total allocation amount is equal to the purchase price reduced by a contribution charge of 2.50% and any applicable guarantee charges. Details of guarantee charges are set out in the description of the portfolio/s below. The investment account will be debited with the amount of each annuity instalment and a policy charge of R7.50 per month. The value of the investment account will reflect the returns earned on the various portfolio/s and funds selected by the annuitant from time to time, as adjusted for any taxes levied, expense charges, and shareholder participation (if applicable). The total allocation amount will be invested in the portfolio/s as indicated in the schedule. Where applicable, the portfolios will operate as follows: ABC LIFE MONEY MARKET FUND The applicable allocation amount is used to purchase units in this fund. Units are purchased at the adjusted price ruling not later than five days following the date of receipt of the purchase price. The adjusted price is the price quoted by ABC LIFE Unit Trusts adjusted to reflect the daily income received or accrued to the fund net of any tax payable and the service charge levied by ABC LIFE Unit Trusts.
88
ABC LIFE
A management fee of 0.16% of the value of the investment account attributable to this fund will be levied monthly by selling units at the adjusted price. LIFESTYLE BALANCED BONUSES, EQUITY LINKED ANNUITY PORTFOLIO, PROPERTY CPI PORTFOLIO AND GLOBAL MANAGED PORTFOLIO For each of these portfolios, the applicable allocation amount is determined after deduction of a guarantee charge of 1.00% and participates in surplus derived from capital appreciation and investment income on the assets underlying the portfolio. In the case of the global managed portfolio, in order to cover the costs of acquiring foreign assets, this allocation amount is determined after deduction of a fee of 1,5%. An equitable share of not less than 90.00% of the surplus (in the case of the equity linked annuity portfolio, all surplus) is declared as a bonus, after the deduction of provision for taxes payable and an ongoing monthly management fee of 0,125% of the value of the investment account attributable to the portfolio. The bonuses are declared annually (free of administrative charges) and credited to the investment account. RSA FUNDS For each of these funds, the applicable allocation amount is used to purchase units in the fund selected. In order to cover the costs of acquiring and managing foreign assets, this allocation amount is determined after deduction of a fee of 1,5%. Units are purchased based on the gross selling price ruling not later than five days following the issue date. The gross selling price is the price, published by the fund manager, increased by any purchase fees levied by the fund, converted to rand at the ruling exchange rate, and adjusted for an allowance for capital gains tax payable. Income distributions, if any, received or accrued from the unit trust funds will be adjusted for tax and used to purchase units at the gross selling price. A management fee of 0,16% of the value of the investment account attributable to these funds will be levied monthly by selling units at the repurchase price published by the unit trust’s management company. FRANK RUSSELL RSA FUNDS For each of these funds, the applicable allocation amount is used to purchase units in the fund selected. Units are purchased at the gross selling price ruling not later than five days following the date of receipt of the purchase price. The gross selling price is the basic price quoted by the unit trust’s management company increased by any purchase fees levied, and adjusted for an allowance for capital gains tax payable. Income distributions, if any, received or accrued from the unit trust funds will be adjusted for tax and used to purchase units at the gross selling price.
89
ABC LIFE
A management fee of 0,16% of the value of the investment account attributable to these funds will be levied monthly by selling units at the repurchase price published by the unit trust’s management company. WRAP FUNDS Each wrap fund consists of portfolios of unit trusts that have been grouped together in accordance with the stated investment objective. In order to achieve the stated investment objective, the portfolio manager appointed by ABC LIFE will in its sole discretion, re-evaluate the investment profile of each wrap fund and make appropriate changes. Units in the wrap fund are purchased at the gross selling price ruling not later than five days following the issue date. The gross selling price is the basic price quoted by the appointed portfolio manager increased by any purchase fees levied and adjusted for any capital gains tax payable by ABC LIFE in respect of the units. Any income distributions received or accrued from the unit trust funds will be adjusted for tax and used to purchase units at the gross selling price. A management fee of 0.18083% (including a wrap management fee of 0.02083%) of the value of the investment account attributable to these funds will be levied monthly. Selling the units at the repurchase price published by the appointed manager will cover this. The value of the investment account at any time is the balance held in the investment account, including the value of any units held calculated at the adjusted price. The annuitant fully understands the implications, nature, operation, and suitability (financial or otherwise) of this contract and the portfolio/s. The annuitant has fully investigated any and al representations made to him/her by any person. ABC Life is the sole holder of all rights relating to the assets underlying this contract. 3. INVESTMENT PERFORMANCE GUARANTEE On the tenth contract anniversary and on every fifth contract anniversary thereafter certain guarantees may apply. The guarantees will be based on the investment performance guarantee and may be cancelled or amended in accordance with ABC LIFE’s practice at the time.
90
ABC LIFE
4.
CHANGES TO SELECTED PORTFOLIOS (SWITCHES) Switches will be allowed subject to ABC LIFE’s practice at the time, provided that no switches will be allowed during the lump sum phasing in period. At the commencement date of this contract it is ABC LIFE’s practice to allow switches free of charge. Any unit purchase as a result of a switch, will be made at the same price as would be used for any allocation amount.
5.
ADDITIONAL PURCHASE PAYMENTS Subject to the practice and requirements of ABC LIFE at the time, the annuitant may make additional purchase payments to this contract, provided that the amount of any such additional purchase payments constitutes a transfer from an approved fund.
6.
BENEFITS ON DEATH On the death of he annuitant / life assured, the life policy sum assured is payable. The life policy sum assured is equal to a return of the purchase price, as well as any additional purchase payments, less any annuity instalments paid and charges levied, together with any remaining surplus attributable to the contract, as determined by the actuary of ABC LIFE from time to time.
7.
BENEFICIARY The annuitant may at any time appoint a beneficiary to receive the life policy sum assured or remove such beneficiary. The appointment or removal of a beneficiary will not be binding on ABC LIFE unless it is recorded by ABC LIFE.
8.
ADJUSTMENT OF BENEFITS In the event of: - the introduction of or any change in the rate of capital gains tax affecting this contract or - an amendment to any legislation levying tax of any kind or any similar levies or - a change in the interpretation or understanding of legislation levying tax of any kind or any similar levies ABC LIFE reserves the right to appropriately adjust the benefits payable under this contract, including any guarantees.
91
ABC LIFE
9.
GENERAL Except as provided herein, the annuitant’s right to benefit in terms of this contract shall not be capable of surrender, commutation, or assignment or of being pledged as security for any loan. SPECIAL CONDITIONS RELATING TO ELECTRONIC APPLICATIONS The owner of this contract has signed client authority or client transaction authority, the term of which form part of this contract.
Mrs Sandra Francis PO Box 10599 Durban 4000
1 October 2004 Our ref: Claims /MVD
Dear Madam,
Contract number: 6798123 Life Assured: Sandra Francis We have acknowledged receipt of your maturity claim. In order for us to process with the claim, the following documents needs to be submitted before payment can be made: Maturity option form Proof of identity document Payment account details
On receipt of the above, the claim would be settled and the amount of R160 368.35 would be transferred into your account.
Yours sincerely Colleen Smith Claims Department
92
ABC LIFE
CASE STUDY 4 - FUNERAL CLAIM APPLICATION FOR PAYMENT OF FUNERAL BENEFITS ON A GROUP SCHEME
1. DETAILS OF MEMBER Name of Scheme: IQ Provident Fund Employer: IQ Systems Name of Member: Simon Sithole Member’s ID No: 7002205816086 2. DETAILS OF CLAIM Name of Deceased: Simon Sithole Date of Death:30.08.2004 Scheme No: 0056784 Employer’s Ref No: 002365 Member No: 201
Relationship of deceased to member (tick applicable blocks): a. Member b. Spouse X By Marriage Custom c. Unmarried child AND Under age 14 Age 14 21 Age 21-25 (studying) Over age 21 handicapped Own Stepchild Legal Adoption Other
Cause of Death:Pneumonia (Please attach original death certificate or a copy certified by the employer) 3. DETAILS OF PAYEE Please confirm bank details: Bank: ABSA Branch Name: Braamfontein Account Type: Savings
Branch No: 205145 Member No: 201 Account No: 5218000156
93
ABC LIFE
4. EMPLOYER‟S DECLARATION It is declared that the member commenced employment on: 01.07.2000 and was actively in service on the date the benefits are claimed and that the deceased satisfied the conditions to be an eligible member/spouse/child/ as the cause may be. ……………… Certified that the above is correct. Date: Authorised signatory:
94
ABC LIFE
IQ PROVIDENT FUND FUND NO: 0056784 MEMBER BENEFIT STATEMENT Effective 1 September 2004 MR S SITHOLE PERSONAL DETAILS Surname First Names Category of Membership Employee Reference No Fund Membership No Date of Birth Normal Retirement Date Normal Retirement Age Date Joined Company Date Joined Scheme Pensionable Service Date Salary Sithole Simon Staff 002365 201 20.02.1970 01.03.2035 65 01.07.2000 01.07.2000 01.10.2000 R 36 000
MONTHLY CONTRIBUTION DETAILS Member (R) Provident Fund Contributions Total Available for Investment Approved Risk Benefits Management Fee Total Payable 150.00 150.00 0.00 0.00 150.00 Employer (R) 150.00 150.00 125.00 22.50 297.50 TOTAL (R) 300.00 300.00 125.00 22.50 447.50
NORMAL RETIREMENT BENEFIT Illustrative Retirement Account for Provident Fund at Normal Retirement Age 000.00 R 210
95
ABC LIFE
BENEFIT SHOULD YOU WITHDRAW TODAY
Resignation benefit at date of statement 100% of accumulated regular contributions plus investment growth
Amount (R) member 6250.00
100% of the accumulated employer contributions 5890.00 plus investment growth Total benefit 12140.00
96
ABC LIFE
BENEFIT PAYABLE IF DEATH OCCURS In the event of your death at the date of this statement A cash payment calculated as follows:
Resignation statement
benefit
at
date
of Full Entitlement
Accepted Cover 6250.00 5890.00 12140.00 108 000.00 5 000.00
100% of accumulated regular member 6250.00 contributions plus investment growth 100% of the accumulated employer 5890.00 contributions plus investment growth Total Portion of account payable Funeral benefit your retirement 12140.00 108 000.00 5 000.00
Total insured death benefit paid
97
ABC LIFE
FUNERAL BENEFIT CLAIM ADMISSION 5. DETAILS OF MEMBER Name of Scheme: IQ Provident Fund Employer: IQ Systems Name of Member: Simon Sithole Member’s ID No: 7002205816086 6. DETAILS OF CLAIM Name of Deceased: Simon Sithole Date of Death:30.08.2004 Scheme No0056784 Employer’s Ref: No002365 Member No:201
Cause of Death: Pneumonia ……………………………………………………….. (Please attach original death certificate or a copy certified by the employer) ________________________________________________________________________ Office Use Only Additional Requirements: None : Claim Notification: Death Certificate: Proof of Age of Deceased: Proof of Relationship to Deceased: Date Req Date Received
31.08.2004………………03.09.2004 31.08.2004…………… 31.08.2004…………… ……………… 03.09.2004 03.09.2004
…………………
Comments/Notes: …………………………………………………………………………. ……………………………………………………………………………………………….. Done By: …C Crichton………………………. Checked by: L Dante…………………………… Date: 05.09.2004……………………………… Admitted by: L Dante……………… Date: 05.09.2004……………………………………. Date: 05.09.2004……………………………….
98
Date: 05.09.2004……………….
ABC LIFE
PAYMENT AUTHORISATION CHECKLIST (Version 2)
Administrator‟s Full Name
C Crichton Request Number Scheme No: 0056784 Member No: 201
Claimant‟s Details Administrator to Complete)
Scheme Name: IQ Provident Fund Member Name: Simon Sithole
Payee’s Full Name/s and Surname/s: Rose Sithole Type of Claim Withdraw Retirement Early Retirement Death Disability Funeral X P Sithole Other Specify
BANK ACCOUNT DETAILS (ADMINISTRATOR TO COMPLETE) Standard ABSA X Nedbank FNB
Accountholder’s Name Other - Specify
Bank Branch Name 205145 Letter from bank
Account Number What proof of bank account?
5218000156 Original bank statement
Bank Branch Code Common bank account list Other Specify
Cancelled cheque
If bank account details on this form, on the system and on original documentation do not match, then this form requires authorization from Financial Control before proceeding. FINCON Authorisation: CHECKLIST (Insert “Yes, „No‟ or „”N/A”‟ (not applicable) in relevant empty blocks.) Name Signature
1 Request Load
2 Release/ Admit
3 Process/ Release
4 Payment 1
5 Payment 2
IT IS THE ADMINISTRATOR’S FUNCTION TO ENSURE THAT ALL THE DOCUMENTATION REQUIRED FOR COMPLETION OF THIS CHECKLIST IS IN THE FILE AND FLAGGED FOR EASY REFERENCE. Original withdrawal/claim included? form
99
ABC LIFE
If form is a copy, only accept if claim amount < R5 000. Is it signed by an authorised signatory? Have any alterations been countersigned by the authorized signatory? Are the member details (surname, initials) the same as on this form? Does the claim type (withdrawal, death etc.) match the original form? Is the member a valid member on the scheme? (recent mbs or scheme schedule from this fund available) Is net benefit amount on the calculation sheet, after tax and any other deductions, the same as the system? Is the fund in a credit control situation? For EFT’s: Do the bank details on this form correspond to the original cheque or bank statement? Do bank details on this form correspond to claim details on the system? (bank name, branch name, branch code, account no.? For CHEQUES: Do the payee details on the system match the withdrawing member exactly (surname, initials)? If the payment is to another financial institution, reject the cheque and return to administrator to arrange an EFT.
X X
X X
X X
X X
X X
X X
X X
X X
X X
X X
X
X
X
X
X
X
X
X
X
X
100
ABC LIFE
DO NOT AUTHORISE HERE OR ON THE SYSTEM UNLESS YOU HAVE ANSWERED YES OR N/A TO EVERY OPEN BLOCK ABOVE, IN THE COLUMN APPICABLE TO YOUR FUNCTION. PLEASE QUERY WTH PREVIOUS AUTHORISER IF PRIOR DATE MORE THAN FIVE DAYS OLD. AUTHORISATION STEPS 1. Request (Compass) Load Claim (Legacy 2. Release (Compass) Admit Claim (Legacy) 3. Process (Compass) Authorise Request (Legacy (3) 4. Payment Approval #1 (Compass)/ Authorisation Instruction #1 (Compass) 5. Payment Approval #2 (Compass)/ Authorisation Instruction #2 (Legacy) NAME (PRINT) C. CRICHTON C. CRICHTON L. DANTE L. DANTE SIGNATURE DATE 05.09.2004 05.09.2004 05.09.2004 05.09.2004
BELOW R10 000
05.09.2004
101
CASE STUDY 5 – RETIREMENT CLAIM Retirement Claim for L. Piper Assume that:
A certified copy of the member‟s IDS has been received
……………………………………………………………………………………………………………… ABC LIFE Retirement Notification Form To be completed by the member: Name of Scheme: 4U2C Provident Scheme Name of Employer: 4U2C (Pty) Ltd Member‟s Name: L. Piper Date of Birth: 25.05.1945 Date of Retirement: 01.06.2004 Scheme No: 005268 Membership No: 365 ID or Passport No: 4505250015083 Employer Ref. No: 222
Pension Funds Only
Provident Funds Only Do you wish to receive the full benefit in cash? Do you wish to purchase a pension? Do you wish to invest the money in an individual policy? If “Yes”, please state the amount you would like to invest: Payment Details I request ABC Life to pay the benefit due by direct deposit into my account at: Name of Bank: Nedbank Name of Branch: Bedfordview Branch Number: 192505 Account Number: 1587956 Type of Account: Current (An original cancelled cheque or an original account statement and a copy of the member‟s ID document must be attached for verification purposes.) YES X YES YES R NO NO X NO X
102
Note: 1. For reasons of security, ABC Life strongly recommends payment by direct deposit. If you request a cheque, you indemnify ABC Life and the scheme should the cheque be stolen. Upon payment in terms of the above instructions, the scheme shall have no further liabilities in respect of the member. ----------------------Date
2.
----------------------------------------------Member’s Signature
103
To be completed by the Scheme’s Authorised Signatory The member is to retire in terms of the following provisions of the rules (please tick as appropriate): Attainment of normal retirement age Early retirement with the consent of the X Employer Early retirement due to ill-health (medical evidence may be required) Late retirement May the member commute a portion of X his/her pension as elected above? May the member receive pension as elected above? DOCUMENTS REQUIRED 1. Proof of Age 2. SARS A and D 3. Application for Annuity (where pension is required) 4. Form IRP2 (where pension is required) Are there any outstanding housing loans for this member? (This question must be answered.) Enclosed Yes X To follow No X X Enclosed Enclosed Enclosed To follow To follow To follow a modified Yes No
No
104
If “Yes”, please give details: ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………
-----------------------------------------------------------Authorised Signatory Company Stamp:
------------------------------------Date
105
REQUEST FOR A TAX DEDUCTION DIRECTIVE FORM A & D PENSION AND PROVIDENT FUNDS
YEAR OF ASSESSMENT ENDED ON: Member Details Surname: First Name: Date of Birth: Other Identification: Piper Lilian 25.05.1945
2004.02.29
ID Number: 4505250015083 Specify Other Identification:
If the taxpayer/member is not registered for income tax, select one of the following reasons: SITE If other, provide reason: R114980 Employee No: 5026 Annual Income: Residential Address: No. 52, Balmoural Estate, Peach Rd, Belgravia Postal Code: 2037 Postal Address: Fund Details Name of Fund: Contact Person: Tel No: Fund Approval Membership No: Postal Address: PO Box 54 Johannesburg Postal Code: 2000 Details of Gross Lump Sum Due Reason for Directive: Death Retirement Date of accrual: 31.05.2004
106
Unemployed
Other
4U2C Provident Scheme J Doe 555-5556 18.204.00268 Type of Fund: 365 Provident Indicate whether this fund is: Public sector fund Approved fund Other X Pension X
Retirement due to ill-health X Provident fund deemed retirement
Gross amount payable:
R322 955.00
In the case of a provident fund, total contributions made by the member: R95 465.00 Period taken into account in calculating the lump sum benefit in terms of: Years of membership or years of employment: Date from: Date to: No Date on which the member became a member of the fund: Are you aware that any lump sums have accrued to the Yes member from this fund or any other fund?
If yes, provide the particulars of the benefits paid: -------------------------------------------------------------------------------------------------------------------------------------------------------
107
Details of Salary Earned Highest average salary earned by the taxpayer during any five consecutive years in the service of the employer during membership of the fund Start Date 1999.06.01 2000.06.01 2001.06.01 2002.06.01 2003.06.01 End Date 2000.05.31 2001.05.31 2002.05.31 2003.05.31 2004.05.31 Salary 88 562.00 89 984.00 95 028.00 104 764.00 114 980.00
Average for the five years or lesser period if employee 493 318.00 employed for lesser period. NOTE: Salary includes any amount received or receivable annually under a contract of service including cost of living allowances, commission, share of profits, but not occasional bonuses or fees which were dependent on the whim of the directors or employers. Details of Employer Name: PAYE Reference: Contact Person Telephone No: Postal Address: Physical Address 4U2C (Pty) Ltd 733045020090 B. Cause 555-5528 PO Box 54, Johannesburg, 2000
108
Rules of the 4U2C Provident Scheme – Schedule Part B (relating to retirement benefits only)
Category Number Eligibility: - Max Age - Min Age Normal Retirement Age: Member Contributions: - Percentage of salary
1
65 18 65 5%
Employer Contributions: - Percentage of fund salary 7.5% - Frequency of payment Monthly Retirement Benefits The member‟s share of fund shall be paid as a lump sum or used to purchase a pension.
ABC Life system records PAYMENT DETAILS Request no. Payment no. Payment method Authority Status Reference no. Payee name Payee ID no. Payee address 56056 1 EFT Fully 4 67895 Payment date Status date Payment user Payment amount Proc date Group no. 01.06.2004 01.06.2004 JFD2007 322 955.00 21.06.2004 6875 Payment system Language code Related policy no. Tax amount Reason PMS 1 None 36 531.20 105 RETPMT: Retirement Claim
Lilian Piper 4505250015 083 No. 52, Balmoural Est, Peach Rd, Belgravia
Payee acc Branch code Cheque no.
1587956 192505 N/A
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Letter confirming payment
Mr D. Crause Profin Brokers (Pty) Ltd PO Box 689 Johannesburg 2000 Dear Sir 4U2C Provident Scheme – 005268 Retirement: L. Piper – 365 ID number: 4505250015083 Retirement: Effective Date: 1 June 2004 We confirm that the above member has retired from the scheme and the retirement benefit payable is in accordance with the option selected on the retirement notification. Full and final settlement of the retirement benefit has been made. The benefit amount and payment details are as follows: Gross Amount Less Tax Net Amount Paid The amount was paid into: Bank: Branch: Account Number: Nedbank Bedfordview 1587956 R322 955.00 R 36 531.20 R286 423.80
In the event of any queries, please contact your administrator on (011) 555-5556. Yours faithfully John Doe Administrator ABC Life
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ADDENDUM 2
All qualifications and unit standards registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source. SOUTH AFRICAN QUALIFICATIONS AUTHORITY REGISTERED UNIT STANDARD: Assess a long term insurance claim SAQA US ID 14431 SGB NAME SGB Financial Services UNIT STANDARD TITLE Assess a long term insurance claim ABET BAND Undefined PROVIDER NAME
FIELD DESCRIPTION Business, Commerce and Management Studies UNIT STANDARD CODE UNIT STANDARD TYPE
SUBFIELD DESCRIPTION Finance, Economics and Accounting NQF LEVEL Level 4 CREDITS 2 SAQA DECISION NUMBER SAQA 0639/01
BUS-FEA-0-SGB FinS Regular REGISTRATION START DATE 2001-12-05
REGISTRATION END REGISTRATION DATE NUMBER 2004-12-05 14431
PURPOSE OF THE UNIT STANDARD This unit standard is intended for people who work in long term insurance and who are required to understand how claims are processed. The qualifying learner is capable of: Collating the documents required to process a long term insurance claim. Analysing a long term insurance claim and confirming the payment amount. Interpreting evidence and making a decision to accept, refer or reject a claim. Implementing and communicating the decision.
LEARNING ASSUMED TO BE IN PLACE There is open access to this unit standard. Learners should be competent in
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Communication and Mathematical Literacy at Level 3 and the unit standard Underwrite a standard risk in long term insurance: level 4. UNIT STANDARD RANGE The typical scope of this unit standard is: Claims include benefits for death, funeral, retirement, maturity, disability and additional illness/disease related benefits. Checking for validity includes checking that the product is in force and that membership of a retirement fund is active.
The documents required once a decision is accepted by the claimant include claim statements and Income Tax Certificates. Specific Outcomes and Assessment Criteria: SPECIFIC OUTCOME 1 Collate the documents required to assess a long term insurance claim. ASSESSMENT CRITERIA ASSESSMENT CRITERION 1 1. A claim is received, recorded and checked for validity. ASSESSMENT CRITERION 2 2. The relevant documents required by the circumstances of an event are identified and supporting documentation that may be required in terms of legislation or industry requirements is collected and presented in a portfolio for at least 5 claims or case studies. ASSESSMENT CRITERION 3 3. The claim benefit amounts for the five claims or case studies are determined from records relating to the policies and rules. ASSESSMENT CRITERION 4 4. The need for records to be updated and the procedures applied in updating records are explained with reference to a selected system. ASSESSMENT CRITERION 5 5. The implications if records are not updated accurately are explained with reference to the consequences for the policyholder and the organisation.
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SPECIFIC OUTCOME 2 Analyse a claim and confirm the payment amount. ASSESSMENT CRITERIA ASSESSMENT CRITERION 1 1. The documents for the five claims in the portfolio are analysed to ensure that they have been completed correctly. ASSESSMENT CRITERION 2 2. Policy conditions, fund rules and medical information applicable to the claims are analysed and applied to the five claims or case studies. ASSESSMENT CRITERION 3 3. Legal applications, industry agreements and practices associated with the payment of claims are explained and applied to the five claims or case studies. ASSESSMENT CRITERION 4 4. The benefit amount of each of the five claims or case studies is confirmed according to the provisions of the specific contracts. SPECIFIC OUTCOME 3 Judge whether the cause of the event matches the predicted profile. OUTCOME NOTES Use the trends and predictions established by underwriting at acceptance to judge whether the cause of the event matches the predicted profile. ASSESSMENT CRITERIA ASSESSMENT CRITERION 1 1. The cause of death is judged against the expected mortality and morbidity profiles used in underwriting. ASSESSMENT CRITERION 2 2. Significant variations from the underwriting profile are identified and evidence is obtained to support or clarify the variation. SPECIFIC OUTCOME 4 Interpret evidence and make a decision to accept or reject the claim. ASSESSMENT CRITERIA
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ASSESSMENT CRITERION 1 1. The evidence in the five claims or case studies is interpreted and a decision or recommendation is made in each case. ASSESSMENT CRITERION 2 2. The basic checks for fraud are explained and applied to the five claims or case studies and an indication is given of the action that can be taken if fraud is confirmed. ASSESSMENT CRITERION 3 3. A final decision is made and supported on whether to accept, refer to an outside professional or reject the claim for each of the five claims or case studies. ASSESSMENT CRITERION 4 4. The implications if fraud is suspected and proved are explained with reference to the claimant and the organisation. SPECIFIC OUTCOME 5 Implement and communicate the decision. ASSESSMENT CRITERIA ASSESSMENT CRITERION 1 1. Reasons why a claim will/not be paid out are given for each of the five claims or case studies and the decision is communicated to the claimant in a role play. ASSESSMENT CRITERION 2 2. The documents required once a decision is accepted by the claimant are identified and the decision is communicated in writing with the required documentation. ASSESSMENT CRITERION 3 3. The payment options available under specific products are explained for each of the five claims or case studies. ASSESSMENT CRITERION 4 4. The prescribed method of payment for specific claims applicable to long term insurance benefits is explained and applied to the five claims or case studies. ASSESSMENT CRITERION 5 5. Records of the five claims or case studies are updated using a specified system.
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UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS This unit standard will be internally assessed by the provider and moderated by a moderator registered by INSQA or a relevant accredited ETQA. The mechanisms and requirements for moderation are contained in the document obtainable from INSQA, INSQA framework for assessment and moderation. Critical Cross-field Outcomes (CCFO): UNIT STANDARD CCFO IDENTIFYING Learners are able to identify and solve problems in which responses show that responsible decisions using critical and creative thinking have been made in making a recommendation and a final decision to accept, refer or reject a claim. UNIT STANDARD CCFO ORGANIZING Learners are able to organise and manage themselves and their activities responsibly and effectively in assessing claims. UNIT STANDARD CCFO COLLECTING Learners are able to collect, organise and critically evaluate information needed to validate and assess a claim. UNIT STANDARD CCFO COMMUNICATING Learners are able to communicate effectively using visual, mathematics and language skills in the modes of oral and/or written presentations in calculating the payment amount, and informing the claimant of the decision in role play and in writing. UNIT STANDARD CCFO SCIENCE Learners are able to use science and technology effectively and critically showing responsibility towards the environment and the health of others in accessing information to assess a claim and updating the claim records. UNIT STANDARD CCFO DEMONSTRATING Learners are able to demonstrate an understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation by understanding the implications if records are not kept accurately and if fraud is suspected. UNIT STANDARD CCFO CONTRIBUTING Learners are able to be culturally and aesthetically sensitive across a range of social contexts in conveying a decision to a claimant.
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UNIT STANDARD NOTES Practical work experience: Before being credited with this unit standard learners are required to have a minimum of 20 hours experience in claims assessing and processing. All qualifications and unit standards registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.
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