Fill - Free fillable Funeral Claim Form PDF form

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.

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

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

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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