Liberty Group Limited (registration no.

1957/002788/06) - an Insurer and an Authorised Financial Services Provider

(no. 2409)
Liberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001
PO Box 10499, Johannesburg, 2000
Contact Centre number: 0860 456 789 / +27 (0)11 558 4871
Email address: info@liberty.co.za

CLAIMANT’S STATEMENT FOR DEATH CLAIM

(EXCLUDES RETIREMENT ANNUITY, PENSION/PROVIDENT FUND)
We are required to share, collect and process your Personal Information (PI). Your PI is collected and processed by our staff, representatives or sub-
contractors and we make every effort to protect and secure your PI. You are entitled at any time to request access to the information Liberty has
collected, processed and shared.

Please send the completed form to Liberty by:

• Email: info@liberty.co.za Post: PO Box 10499, Johannesburg, 2000

Standard requirements – please attach copies of the following documents

Death certificate
Beneficiaries’ ID document or copy of the back and front of ID smart card
Passport if beneficiary is overseas
Unabridged birth certificate if beneficiary is a minor
Proof of each beneficiary’s bank account details (original bank statement/cancelled cheque)
Notice of death (BI 1663 / DHA 1663) obtainable from the doctor who certified the death or the undertaker
Extract of Medical History (PMA) if the policy is less than 3 years.
In the event of unnatural death:
Police statement completed by investigating officer.

NOTES:
• Please note that all fields in this form must be completed in full in order to proceed with the claim.
• If the beneficiary lives abroad and is applying for foreign exchange control approval the above requirements must be certified and
contain the full name/s, surname, designation and physical address of the Commissioner of Oaths or Notary Public. These must
appear on a stamp or be clearly handwritten and recorded that the documents are “certified a true copy of the original”.
• Foreign exchange control approval takes a minimum of 8 weeks from date of submission of all the documents required by Standard
Bank, in order to process this application.
Section 1 – Deceased’s details

Policy number/s

Surname

First name/s Initials

ID number

Date of death Place of death

Tax reference number (compulsory for tax purposes)

Medical aid scheme

Medical aid number

Executor’s details: Name Contact number
Email address

Cause of death

Genito urinary disorder e.g. kidney failure, endometriosis, hysterectomy, multi Cancer
organ failure Cardiovascular disease e.g.heart condition
Central nervous system e.g. Parkinsons, multiple sclerosis, epilepsy, motor neuron Blood disorder e.g. septicaemia, anaemia
Gastro intestinal disorder e.g. gall bladder, liver, stomach, pancreas, Crohns Motor vehicle accident
Endocrine disorder e.g. diabetes, thyroid, pituitary glands, malnutrition Murder
Cerebrovascular disease e.g. stroke, aneurysm Suicide
Respiratory disorder e.g. pneumonia, asthma
Other
1.1 Was death reported to police? Yes No
If “Yes”, please provide case number
1.2 Was the deceased employed at the date of death? Yes No
If “Yes”, state occupation at date of death

Please note that in the event of any modification or variation of this standard form Liberty will regard this form as being
invalid and of no force and effect. Do not sign blank or incomplete forms.
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1.3 Name of deceased's employer at date of death

1.4 When did the deceased first consult a doctor for his/her last illness?
Please complete the table below regarding information of every doctor who attended to the deceased during his/her last illness and during the five
years preceding his/her (need only be completed for policy with life cover.)

Doctor’s name Contact details Date of attendance Reason

Section 2 - Claimant’s details

First claimant
Would you like to invest your funds and receive a monthly income? Yes No
If "No", please note the following:
• Payment will only be made once all Liberty's requirements are met, including receipt of a finalised Tax Directive issued by the South
African Revenue Service (SARS).
• Should an IT88 (stop order) be attached to the directive received, we are oblidged by law to deduct the tax and/or the IT88 as per the tax
directive. The SARS directive will not be cancelled.
Please ensure Section 4 - Financial Adviser's details is completed. If you do not have a Financial Adviser, a Liberty Financial
Adviser may contact you if required.
Surname

First name/s Initials

ID number
Language preference: English Afrikaans
Marital status: Single Engaged Married Date of marriage

Widowed Separated Divorced Date of divorce

Contact numbers: Work Cell Fax

Email address

Residential address Postal code

Postal address Postal code
What was your relationship to the deceased?

Would you like a Financial Adviser to contact you to provide financial advice? Yes No
Have you officially emigrated? If “Yes, please complete the Exchange Control form. Yes No
SARS Income tax number

Banking details
Account holder’s name

Bank name

Account number

Branch name Branch code

Account type: Cheque Savings Transmission
Account holder relationship: Own Joint

Second claimant
Would you like to invest your funds and receive a monthly income? Yes No
If "No", please note the following:
• Payment will only be made once all Liberty's requirements are met, including receipt of a finalised Tax Directive issued by t he South
African Revenue Service (SARS).
• Should an IT88 (stop order) be attached to the directive received, we are oblidged by law to deduct the tax and/or the IT88 as per the tax
directive. The SARS directive will not be cancelled.
Please ensure Section 4 - Financial Adviser's details is completed. If you do not have a Financial Adviser, a Liberty Financial
Adviser may contact you if required.

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Second claimant - continued
Surname

First name/s Initials

ID number

Language preference: English Afrikaans

Marital status: Single Engaged Married Date of marriage

Widowed Separated Divorced Date of divorce

Contact numbers: Work Cell Fax

Email address

Residential address Postal code

Postal address Postal code

What was your relationship to the deceased?

Would you like a Financial Adviser to contact you to provide financial advice? Yes No
Have you officially emigrated? If “Yes, please complete the Exchange Control form. Yes No
SARS Income tax number
Banking details
Account holder’s name
Bank name

Account number
Branch name Branch code

Account type: Cheque Savings Transmission

Account holder relationship: Own Joint

Section 3 - Death claim declaration (legal guardian to sign for minor.)

We the claimant/s, claim the benefits of the policy/ies and declare that the answers and statements are true to the best of my/our knowledge and belief,
and that I/we have withheld no material fact.
I/We agree that:
• Any written statements and affidavits including supporting documents provided in support of this claim shall form part of this claim.
• The fact that Liberty provided this form to me/us to complete, does not constitute admission that I/we have a valid claim.
• Any benefits payable in respect of this claim shall be forfeited if I/we or anyone acting on my/our behalf or with my/our knowledge have withheld
any material fact or submitted any false information in respect of the claim.
• By signing this document, I/we confirm that I/we have a legal right and entitlement to claim the relevant benefits. Upon payment of the benefits,
I/we absolve and discharge Liberty Group Limited, including their successors, form any claims or further liability which may arise in relation to the
policies mentioned above.
Signed at on

Signature of first claimant Signature of second claimant

Signature of witness

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Section 4 - Financial Adviser’s details

If this section is not completed or you do not have a Financial Adviser, a Liberty Financial Adviser may contact you if required.
Adviser's name
Commision code

Contact numbers: Work Cell

Email

Signature of Financial Adviser

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