RSA DEATH CLAIM FORM

FOR DEATH/FINAL EXPENSES/

FUNERAL CLAIMS
Policy number

Please print in block letters using black or blue ink.

For all claims questions, call 0860 10 2274 or 27 (0)21 503 1802 weekdays between 08:00 and 18:00
or email service@oldmutual.com

To be filled in by the contact person

To process claims efficiently, we may need to contact someone at various stages of the claim. If you are the person we must contact, please fill in this form.

You do not need to be a beneficiary of this death claim to complete this form – but you must be the contact person. Beneficiaries must complete the
separate BENEFICIARY FORM. If you are both the contact person as well as the beneficiary, you must fill in this form as well as the BENEFICIARY FORM.

To find out exactly what documents you need to provide us with for your claim, please ask for our HOW TO SUBMIT A DEATH CLAIM information page.

The contact person is responsible for providing information that is true and accurate, to the best of your knowledge. At the end of this form, you need to sign
to indicate that you have given us true and correct information. You also need to sign your permission for us to confirm your information with any other source.

1. CONTACT PERSON’S DETAILS

Title Mr Ms Mrs Other Initials

First names

Surname

ID number

Relationship to the deceased: Family member Executor of estate

Other (please explain)

Contact numbers
(Work) Code Number

(Home) Code Number

Fax Code Number

Cellphone number

Email address
Residential address
if different to postal
address Postal code

Postal address

Postal code

Are you also a beneficiary of this policy? YES NO If “YES”, please fill in the separate BENEFICIARY FORM.

2. DETAILS OF DECEASED
To confirm information about the deceased, we need to know the following information about the deceased:

Title Mr Ms Mrs Other Initials

First names

Surname
South African ID or Income tax
passport number number

Date of birth
D D M M Y Y Y Y Date of death
D D M M Y Y Y Y

Cause of death: Natural (i.e. old age or illness) Unnatural (i.e. car accident or victim of crime)

Please provide more information about the cause of death.

Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06
1 Death Claim & Beneficiary Claim Form omms 07.2014 L6937
 Was the deceased insured with any other company? YES NO

Company name Policy number

Company name Policy number

3. MEDICAL INFORMATION
a) Please fill this section in. We may need to contact the person who certified the death.
 Please provide the name of the hospital or medical practitioner who certified the death.
Name of
hospital
Contact
person

Telephone Code Number Cellphone number

Email
address
Address

Postal code

b) Medical history of deceased

Please provide the names and addresses of the deceased’s house doctor and any other doctor, hospital or clinic where the deceased received medical
attention.
Name

Address

Postal code

Approximate date of medical attention

D D M M Y Y Y Y
Reason for medical attention.



Name

Address

Postal code

Approximate date of medical attention

D D M M Y Y Y Y
Reason for medical attention.

Name

Address

Postal code

Approximate date of medical attention

D D M M Y Y Y Y
Reason for medical attention.

c) Medical Aid details of deceased

Did the deceased belong to a medical aid? YES NO

Name of Medical Aid

Contact numbers

Member number

Email address

Policy number

Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06
2 Death Claim & Beneficiary Claim Form omms 07.2014 L6937
 4. FUNERAL PARLOUR INFORMATION
We may need to contact the undertaker. Please fill this section in.
Name of
funeral parlour
Contact
person

Telephone Code Number Cellphone number

Email address

Address

Postal code

5. EMPLOYER INFORMATION
We may need to contact the employer. Please fill this section in.
Name of
employer
Contact
person

Telephone Code Number Cellphone number

Email address

Address

Postal code

6. DECLARATION OF CONTACT PERSON

I confirm that all the information provided on this form is true and accurate to the best of my knowledge.
I give Old Mutual consent to confirm the information provided with any other source.

Signed at this day of 20

Signature of
contact person

CORRESPONDENCE DETAILS
Send documents to Old Mutual:
Email service@oldmutual.com
Fax 021 509 2579 (attached email confirming fax number)
Post Death Claims Department
PO Box 1759
Cape Town 8000
South Africa

Policy number Old Mutual is a Licensed Financial Services Provider

Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06
3 Death Claim & Beneficiary Claim Form omms 07.2014 L6937
 RSA BENEFICIARY CLAIM FORM
FOR DEATH/FINAL EXPENSES/
FUNERAL CLAIMS
Policy number

Please print in block letters using black or blue ink.

For all claims questions, call 0860 10 2274 or 27 (0)21 503 1802 weekdays between 08:00 and 18:00
or email service@oldmutual.com
To be filled in by the beneficiary or beneficiaries
Each beneficiary must fill in this form. If there is more than one beneficiary, each beneficiary must fill in a separate form.
If you are also the contact person for a claim, please fill in the CONTACT FORM FOR DEATH/ FINAL EXPENSES/FUNERAL CLAIMS.
To find out exactly what documents you need to provide us with for your claim, please ask for our HOW TO SUBMIT A DEATH CLAIM information page.

1. BENEFICIARY DETAILS
Title Mr Ms Mrs Other Initials

First names

Surname

ID number Income tax number

Relationship to the deceased: Family member Executor of estate Other (please explain)
Contact numbers
(Work) Code Number

(Home) Code Number

Fax Code Number

Cellphone number

Email address
Residential address
if different to postal
address Postal code
Postal address

Postal code

2. BENEFICIARY BANK ACCOUNT DETAILS

Name of bank
Name of
account holder
Branch name Branch code

Account number Account type Current Savings Transmission

Swift/BAN/Sort code (for foreign bank accounts only)

• We pay all claims by EFT into each beneficiary’s bank account.

• We don’t pay in cash or by cheque.
• If you don’t have a bank account, you need to open one.
• The bank account must be in your name.
• We do not pay into third party accounts.
• If you are a minor, you still need a bank account in your name.
• We need you to apply for permission from the South African Reserve Bank before we can pay into a foreign bank account.
• We are not responsible if we pay into an incorrect bank account based on incorrect banking information you gave us.

3. DECLARATION OF BENEFICIARY
I confirm that the information I have provided on this form is true and correct to the best of my knowledge. I agree that I cannot hold Old Mutual responsible if
any money is paid into an incorrect bank account as a result of any information I have given. I give Old Mutual consent to confirm the information on this form
with any other source.

Signed at this day of 20

Signature of beneficiary

PROTECTION OF PERSONAL INFORMATION (PPI)
The Old Mutual Group would like to offer you, on-going financial services and may use your personal information to provide you with information about products
or services that may be suitable to meet your financial needs. Please sms your ID number to 45600 if you would prefer not to receive such information and
financial services.
To view our full privacy notice and to exercise preferences, visit our website on www.oldmutual.co.za Old Mutual is a Licensed Financial Services Provider

Old Mutual Life Assurance Company (South Africa) Limited reg. no: 1999/004643/06
4 Death Claim & Beneficiary Claim Form omms 07.2014 L6937