Funeral claim

Rest Assured claim form

Rest Assured lodges this claim with the underwriter on behalf of the claimant. Claims must be submitted within 6 months of the death.

Reference ____________

1 Policy

Policy number

Main member

Cover

2 The deceased

Full names

Surname

ID / passport number

Date of birth

Date of death

Relationship to main member

Cause of death: Natural Accident Suicide Place: Hospital / clinic Home Elsewhere

3 The claimant

Full name

ID / passport number

Date of birth

Gender

Marital status

Nationality

Cell number

Relationship to the deceased

Source of funds

4 Settlement

Cash to the claimant Exchange the cash benefit for repatriation to: Zimbabwe Botswana Malawi Mozambique Zambia Tanzania DRC

Account holder

Bank

Account number

Account type

Branch code

Benefit (office use)

The underwriter pays the benefit in rand. Repatriation is a service Rest Assured arranges in exchange for that cash amount.

5 Documents to attach

Official death certificate from Home Affairs
Certified copy of the claimant's ID or smart card, both sides
Certified copy of the deceased's ID or smart card, both sides
Claimant's bank statement, not older than 3 months
BI/DHA-1663, all 3 pages, if Safrican asks for it (if it applies)
BI/DHA-1680 if the death was at home (if it applies)
Police or accident report, if the death was unnatural
Passport and work visa, if the deceased was not a South African citizen
Medical report for a stillborn child

6 Declaration and consent

I declare that the deceased was covered on this policy and that these details are true and correct. I authorise Rest Assured to lodge this claim on my behalf. I consent to Rest Assured and the underwriter using my personal information to assess and pay the claim, and to check sanction lists as the law requires (POPIA). If I name a third party to receive the benefit, the underwriter has no further liability once it is paid.

Claimant's signature

Rest Assured officer

Date