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.
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: Beneciary Policyholder
A fully completed and signed Funeral claim form.
A certied copy of the death certicate.
A certied copy of the deceased’s identity document.
A certied copy of the DHA-1663 obtainable from the doctor who declared the death.
A certied copy of the policyholder’s identity document.
A certied 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 ofcer.
A certied copy of the beneciary/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
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:
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 ofce hours are from 8:00 – 17:00.
Momentum may ask for more information or set further requirements if necessary.
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
Date D D – M M – 2 0 Y Y
Policy number 1.
Policy number 2.
Policy number 3.