Fillable FAMILY BENEFIT CLAIM FORM GROUP ASSURANCE GUIDELINES FOR (South Africa Office of the Chief Justice)

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FAMILY BENEFIT CLAIM FORM GROUP ASSURANCE GUIDELINES FOR (South Africa Office of the Chief Justice)

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1
GAP Family Benet NAC Burial Fund Claim Form bds 6.2019 L13492
Old Mutual Life Assurance Company (South Africa) Limited. Reg No: 1999/004643/06
GUIDELINES FOR COMPLETION OF THIS FORM
The following guidelines will help Old Mutual Group Assurance to process your claim quickly and accurately:
1. These claim forms must be completed by an authorised representative of the New Apostolic Church (NAC) Burial Fund
2. Complete the application form fully and in detail as it gives us important information
3. Write your answers in clear black or blue block letters so that it is easy to read
4. If the form is completed electronically, please print, sign, stamp and scan the form to send to us
5. Use the checklist below to ensure that you hand in all the necessary documents
Documents required Tick
Copyofdeathcerticate,certiedbyaCommissionerofOathsortheSAPS
•Ifahandwrittenabridgeddeathcerticateissubmitted,thismustbeaccompaniedbyaletterfromtheDepartmentofHomeAffairswiththe
reasonwhyahandwrittenabridgeddeathcerticatewasprovided.
Noticationofdeath/stillbirthform(DHA1663/BI1663)
Policereportforunnatural/accidentaldeaths
Certiedcopyofmainmember’sidentitydocument
Bankstatementandcertiedcopyofbeneciary’sidentitydocument(ONLYifpayabletobeneciary)
Claim application form completed by the authorised representative of the NAC Burial Fund
Additional documents required if the deceased is an insured family member Tick
Certiedcopyofinsuredfamilymember’sidentitydocument/unabridgedbirthcerticate
Proofofrelationshiptothemember:
•Certiedcopyofmarriagecerticate,or
•BeneciaryNominationForm
Submit the form electronically, by fax or post:
Email gapdeathclaims@oldmutual.com
Fax 0215094669
Address Group Assurance
DeathClaimsTeam(6J)
OldMutual
POBox2386
CapeTown8000
You are welcome to contact us at 021 509 4351 should you require assistance with completing and submitting this form.
Our working hours are Monday – Friday (excluding public holidays): 08:00 – 17:00
Referencesinthisapplicationformto“OldMutualGroupAssurance”actuallyreferto“OldMutualLifeAssuranceCompany(SouthAfrica)Limited”.
PROTECTION OF PERSONAL INFORMATION DISCLOSURE
ThepersonalinformationreceivedbyOldMutualinaccordancewiththiscontractwillbeused,asandwhenappropriate,forthefollowingpurposes:
• Underwriting
• Assessment and processing of claims
• Claimschecks(LifeandClaimsRegister)
• Fraud prevention and detection
• Tracingbeneciaries
• Audit and record keeping purposes
• Compliance with legal and regulatory requirements
• Vericationofthepersonalinformationprovided
PersonalInformationwillbede-identiedwhenusedformarketresearchandstatisticalanalysis.
WhenOldMutualengagesserviceproviderstoprocesspersonalinformationonitsbehalfortorenderservicestoit,OldMutualmaysharesomepersonalinformation
withtheseserviceproviders,subjecttocondentialityagreementsbeinginplacebetweenOldMutualandsuchserviceproviders.Shouldtheseserviceproviders
beabroad,OldMutualwillnotsharethepersonalinformationwiththemunlessitissatisedthatadequatesecuritymeasuresareinplacetoprotectthepersonal
information.
ThePolicyholderisadvisedandencouragedtoinformallmembers/livesassuredthatOldMutualholdsandisprocessingtheirpersonalinformationforthepurposes
notedabove.ThePolicyholderoramember/lifeassuredmayaccessthepersonalinformationrelatingtohimorherand,subjecttotheprovisionsthiscontractmay
requestthecorrectionofanyerrorsorthedeletionofthisinformation.IncertaincasesthePolicyholderandmembers/livesassuredhavetherighttoobjecttothe
processing of their personal information.
ThePolicyholderormembers/livesassuredhavetherighttocomplaintotheInformationRegulator,whosecontactdetailsare:
Website justice.gov.za/inforeg/index.html
Tel 0124064818
Fax 0865003351
Email inforeg@justice.gov.za
OldMutual’sfullprivacynoticecanbeviewedatoldmutual.com/privacy-notice
GROUP ASSURANCE
FAMILY BENEFIT
CLAIM FORM
Old Mutual is a Licensed Financial Services Provider
2
GAP Family Benet NAC Burial Fund Claim Form bds 6.2019 L13492
Old Mutual Life Assurance Company (South Africa) Limited. Reg No: 1999/004643/06
NAC BURIAL FUND DECLARATION AND AUTHORITY TO PAY CLAIM
I, the undersigned, in my capacity as and duly
authorisedtomakethisdeclaration,herebydeclare:
a) That the information provided in this claim is true and correct, and that no information has been omitted or withheld
b) That the insured person whose death gave rise to this claim has in fact died
c) Thatpaymentoftheproceeds,dueinrespectoftheaboveinsuredpersonintermsoftheaforementionedscheme,shallrepresentthefullandnaldischarge
ofOldMutualGroupAssurance’sliabilityinrespectofthisinsuredperson
NACBurialFundindemniesOldMutualGroupAssuranceagainstanyclaimthatmayarisefromanyincorrectinformationprovidedinthisform.
NACBurialFundherebyinstructsOldMutualGroupAssurancetopaytheFamilyCoverbenetduetotheperson.
Signedat on this day of
20
Name
Telephone code number
Email address
Signature
SCHEME DETAILS
Schemename
NAC Burial Fund
Schemecode
96391
MAIN MEMBER DETAILS
First name(s)
Surname
Identity number Dateofbirth
D D M M Y Y Y Y
DateofjoiningFund
D D M M Y Y Y Y
Dateofmember’sdeath
D D M M Y Y Y Y
Maincauseofdeath
DECEASED PERSON’S DETAILS – COMPLETE ONLY IF THE DECEASED IS AN INSURED FAMILY MEMBER
First name(s)
Surname
Identity number
Dateofbirth
D D M M Y Y Y Y
Dateofdeath
D D M M Y Y Y Y
Gestational age of foetus weeks Relationship to the main member
Maincause
of death
PAYMENT DETAILS
• IntermsoftheFamilyBenetpolicycontract,OldMutualmustpaythebenetsstrictlyinaccordancewiththewrittenconrmationandinstructionfromthe
NACBurialFund/Proposer/AuthorisedRepresentative
• ThebenetwillbeelectronicallytransferredtotherelevantbankaccountintermsofthePolicyContract
• Benetpayableto:
Bank account details
Name of
account holder
Identity number Name of bank
Account number Branch code
Beneciary contact details for conrmation of payment
Email address
Cellphone
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FAMILY BENEFIT CLAIM FORM GROUP ASSURANCE GUIDELINES FOR (South Africa Office of the Chief Justice)

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Completed 8 March 2021

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