SLDC001E
Sanlam 02/2011
Licensed Financial Services and Registered Credit Provider (NCRCP43) 2
Policy number
A. Particulars of deceased
Full name and surname
Cause of death Natural Unnatural
Please describe the exact cause of death
Name of doctor or person who certified the death
Telephone number ( )
Name of the undertaker Telephone number ( )
B. Who must Sanlam communicate with
During the claim process we will communicate with the correspondent (persons you choose to receive the correspondence).
Please provide the details of your chosen correspondents.
Spouse or family member
Correspondence language: English Afrikaans
Full names and surname
Relation to deceased
Identity number
Postal address
Contact number
Fax number
E-mail address
Broker or adviser
Correspondence language: English Afrikaans
Name and surname Broker code
Contact number
Fax number
E-mail address
Other (Attorneys, Bank, Executor)
Correspondence language: English Afrikaans
Name of institution or person
Contact person’s name and
surname
Postal address
Contact number
Fax number
E-mail address
C. Review your financial planning
Did you know that you can re-invest the money if you are not ready to make a final decision yet?
If you do not have an adviser or broker assisting you, would you like someone to contact you to assist Yes No
you with your financial planning?
D. Your declaration
I declare that:
I have completed this document or someone has completed it for me with my approval.
I understand the information in this document.
The information in this document is correct.
Full name and surname
Signature Identity number
Date / /
(dd/mm/ccyy)
