1
Funeral claim form
(This form applies to all Funeral policies with Momentum).
All relevant questions are to be completed in full. All supporting documentation must be attached to the report.
Requirements
Please choose the category that applies to you and send us the documents marked as required for the particular category. If the policyholder is deceased,
different documents are needed, as indicated.
Please indicate your role: Beneciary Policyholder
Policyholder Beneciary
A fully completed and signed Funeral claim form.
A certied copy of the death certicate.
A certied copy of the deceased’s identity document.
A certied copy of the DHA-1663 obtainable from the doctor who declared the death.
A certied copy of the policyholder’s identity document.
A certied copy of the claimant’s identity document (if the claimant is not the policyholder).
If the deceased died of unnatural causes, we require the Unnatural death claim form (CLAIM 003)
which must be
completed by the Police Investigating ofcer.
A certied copy of the beneciary/ies identity document/s.
A copy of the bank statement or a cancelled cheque. (According to the Financial Intelligence Centre Act (FICA),
we must identify the roleplayer, and verify information. This means we can ask for additional information and
documents.)
Proof of payment for all funeral costs (if claimant is not the policyholder and the policyholder is deceased).
This only applies to Southern life and Sage Life policies.
Please note: We will not be able to proceed with the claim if all the documents asked for are not attached to this form.
Please email or fax the claim documents to:
E-mail: riskclaims@momentum.co.za
Fax: 012 675 3947 (International: +27 12 675 3947) (Please quote the policy number on the fax.)
Or call us for more information:
Tel: 0860 44 11 11 (International: +27 12 675 3052) Our ofce hours are from 8:00 – 17:00.
Momentum may ask for more information or set further requirements if necessary.
Preferred communication
As part of our claim’s process we will keep your servicing nancial adviser on our system informed of the progress of the claim.
Should you not wish the servicing nancial adviser to remain informed of the progress of the claim, please indicate with a tick.
In the event that you selected the above option, you will be responsible to submit all claim documentation to Momentum directly.
Name and surname
Signature
Date D D M M 2 0 Y Y
CLAIM0090816E
Policy number 1.
Policy number 2.
Policy number 3.
2
Section 1: Details of claimant
Title Initials First name
Surname
Relationship to the deceased
Identity number (RSA residents only) Permanent ID Yes No
Passport number (non-RSA residents only) Date of birth D D M M Y Y Y Y
Passport expiry date D D M M Y Y Y Y
Passport country of issue
Postal address
Postal code
Physical address
Postal code
Telephone - work Fax - work
Telephone - home Fax - home
Cellphone number
E-mail address
Which method of communication do you prefer? Post E-mail What language do you prefer? English Afrikaans
Section 2: Details of the deceased
Title Initials First name
Surname
Identity number (RSA residents only) Permanent ID Yes No
Passport number (non-RSA residents only) Date of birth D D M M Y Y Y Y
Passport expiry date D D M M Y Y Y Y
Passport country of issue
Occupation
Was the deceased employed? Yes No
Name of employer
Physical address
Postal code
Telephone - work Employee number
Date of death D D M M Y Y Y Y
Exact cause of death (please give full details - ‘Natural/unnatural causes’ not acceptable)
If the cause of death is unnatural, we require a completed Unnatural death claim form (CLAIM 003).
Date of funeral D D M M Y Y Y Y
Place/cemetery of burial
Name of funeral parlour
Address of funeral parlour
Postal code
Telephone number of funeral parlour
Name of hospital and place of death
Hospital admission/patient number
Address
Postal code
Name of doctor who certied death
Telephone number
3
Section 3: Bank details of claimant:
Please attach a copy of your bank statement not older than three months or a cancelled cheque. The bank statement must be on a bank letterhead or
have a bank stamp on.
Name of account holder
Bank
Account number
Account type Current Savings Transmission
Branch
Branch code
Signature of account holder
Date D D M M 2 0 Y Y
Section 4: Declaration by the claimant/s
I declare that the information I have given above is true and complete. I consent to Momentum seeking information about this claim from any source it
considers appropriate and I authorise the providing of such information.
Name of claimant
Signature of claimant
Date D D M M 2 0 Y Y
Name of legal guardian/parent/trustee
Signature of legal guardian/parent/
trustee
Date D D M M 2 0 Y Y
Momentum Namibia Limited Metropolitan Place 5
th
Floor Cnr Dr Frans Indongo
& Werner List Street Windhoek PO Box 79 Windhoek Namibia
Tel +264 (0)61 297 3631 Fax +264 (0)61 297 3573
service@momentum.com.na
Reg. No. 91/369
Momentum 268 West Avenue Centurion 0157
PO Box 7400 Centurion 0046 South Africa
ShareCall 0860 44 11 11 Fax +27 12 675 3947
riskclaims@momentum.co.za www.momentum.co.za
Momentum, a division of MMI Group Limited, an authorised financial services and credit provider. Reg. No. 1904/002186/06
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