2.

/ ESKOM COMPULSORY DEATH BENEFIT APPLICATION / NOMINATION FORM FOR BARGAINING UNIT EMPLOYEES FOR ONE SPOUSE / LIFE PARTNER 1 MARCH 2014 / Form no / CDBF
Rev no / 1
Date / Feb 14

Annexure A

WHEREAS ______Unique number: ______

(The employee - Full Names)

enjoys Compulsory Death Benefit cover in terms of the Eskom Conditions of Service “Compulsory Death Benefit Fund” held by Eskom. NOW THEREFORE, the employee hereby:

1. requests Eskom to register one spouse / life partner who shall be the sole insured person to whom the Death Benefit cover shall apply :

………………………………………………………………………………………………………………….

(Spouse / Life Partner’s Name)

………………………………………………………………………………………………………………….

(Spouse / Life Partner’s ID Number and copy of ID document must be submitted with the application)

2. In the event of the death of the registered spouse / life partner the amount payable must be paid to the following beneficiary/ies:-

Note: The ID number and a copy of the ID document of the nominated beneficiary/ies must be submitted with the application.

Note:- The nominee/s must be of sound mind and over 18 years of age

ID Number / Full Names of the beneficiary as they appear on the ID / Date of Birth / Relationship / Percentage

Note:- The cover for the spouse /life partner will terminate when the employee dies, resigns, or retires from the employer.

3.  By signing this form I acknowledge and accept that:-

a.  If I do not nominate any beneficiary in respect of any amounts payable or if a nominated beneficiary is a minor as at the date of death of my spouse / life partner, all the proceeds will be paid to me

b.  Any payment by Eskom will be subject to the death claim in respect of the employee’s registered spouse / life partner being admitted by the Insurance Company underwriting the Compulsory Death Benefit Policy, and shall be in accordance with the terms and conditions of such policy.

c.  Where both my spouse / life partner and I die simultaneously the proceeds will be paid to my estate/ spouse’s estate [delete whichever is not applicable]

d.  Where I predecease my spouse/life partner and the nominated beneficiary, this policy will automatically lapse on the date of my death and no proceeds will be payable.

All previous nomination forms are revoked and Eskom will pay the proceeds in terms of this nomination form.

Thus done and signed at ______on this the ______day of ______20___

______

Employee Signature

WITNESSES:

1. ______2. ______

______

Eskom HR Practitioner

(Accepted on behalf of Eskom SOC Limited and Financial Services Department)