Claim process on death of member
On the death of the member, the death and funeral benefits as per the chosen plan
will be paid to the member’s dependants / employer / beneficiaries. The member’s
fund value as at date of death will be paid in a lump sum to the member’s
dependants / beneficiaries.
The following documentation is required:
- Absa Notification of Death form
- Death and funeral claim form
- Certified copy of death certificate. Only form BI 1663 is accepted. Form BI 5 or
DHA 5 are subject to underwriter approval
- Certified copy of ID document of member
- Certified copy of ID document of person(s) to whom benefit is payable (if
spouse: Marriage certificate/Lobola letter/Letter from employer/Affidavit from
third party stating that member and spouse lived together as husband and
wife, if beneficiary: Letter from employer/Affidavit from third party confirming
the relationship between the deceased and the beneficiary)
- Bank statement of beneficiary
- Certified copy of Statement by Police form if death due to unnatural causes
(Additional documentation may be required)
Please note:
Should a member, spouse or child pass away, the claimant has a six month
period in which to notify the fund in writing. Thereafter there is an additional
six month period in which to submit the relevant death claim documentation.
Should this not take place within the specified time, the claim will not be
processed
1.PARTICULARS OF FUNDName of Fund
Name of Employer
2.PARTICULARS OF MEMBER
2.1 Fund membership number
2.2 Company number
2.3 Surname
2.4 Full names
2.5 Date of birth
2.6 Date of death
2.7 Identity number (attach copy of ID)
2.8 Sex
2.9 Marital status
2.10 Income tax reference number
2.11 Revenue office
2.12 Did the member complete a nomination form? / Yes / No
2.13 Was the member in your full time service on the date of death? / Yes / No
If “NO”, please furnish details
3.DETAILS OF DEPENDANTS OR NOMINEES
3.1 Is the member survived by a dependant and/or nominee / Yes / No
3.2 If 3.1 “YES”, please provide the following details in full:
Full names and surname / Date of birth / ID number / Relationship / Address / Telephone / Bank account details
3.3 If 3.1 “NO”, please provide details of the executor in the estate
NB: If these details are not fully available at time of completing this form, they may be submitted separately once they become known. Completion of this form
should not be delayed if all the details are not available
4.FINANCIAL DETAILS
4.1 Date of last contribution to the Fund
4.2 Amount of last contribution to the Fund / R
4.3 Member’s annual pensionable salary on the date of death / R
4.4 The Fund/employer has the following preferential claim against the member’s benefit in the amount of / R
Housing loan
Fraud/Dishonesty/Misconduct (Please attach a copy of the member’s written admission of liability or court order)
5.DOCUMENTS REQUIRED
Member’s marriage certificate / Two certified copies
Member’s nomination form / Original
Proof of age of member / Two certified copies
Proof of age of dependants and/or nominees / Two certified copies of each
Member’s death certificate / Two certified copies
Revenue Form D completed by the Employer / Original
Revenue Form IRP2 completed by each person who qualifies to receive a spouse’s or children’s pension / Original
The trustees’ instruction for the payment of the benefit / Original
NB. Documents submitted must be either the original or certified copy by a commissioner of oaths.
If these documents are not fully available at time of completing this form, they may be submitted separately once they become available. Completion of this
form should not be delayed if all the documents are not available
6.EMPLOYER’S CERTIFICATION
I hereby certify that the above information is correct.
Date
Capacity
Full names
Signed on behalf of the Employer
Death and Funeral FormTel: 011 846 3717 Fax: 086 753 3843 E-mail:
BTP no: / Employer name:
SUPPORTING DOCUMENTATION (see Death Claim Process for additional documentation)
• A certified copy of the death certificate
• A certified copy of the deceased’s identity document
• A certified copy of the main member’s identity document
• A certified copy of the beneficiary / claimant identity document
• A copy of the BI-1663
• A police report in the case of death due to unnatural causes
• If claimant is a different person/entity from the beneficiary, please attach written authorisation/affidavit from benefit for
claimant to receive claim amount
• Copy of bank statement of beneficiary / claimant
The underwriter will verify all deaths with the Department of Home Affairs. Depending on the circumstances, there may
be other requirements. Please ensure that you meet all the requirements that we have set out in this form.
A. DETAILS OF MEMBER
Surname and initials
First names
Date of birth
ID number
Reference number
Marital status
B. DETAILS OF DECEASED
Surname and initials
First names
Date of birth
ID number
Relationship to member
Date of death
Cause of death
Place of death / (Name of city/town)
If unnatural, please state the exact cause of death
Plan choice / Claim amount
Name and address of doctor/hospital who/which certified the death certificate
Name
Adress
Code
Telephone number
Did the deceased commit suicide or was his/her death the result of his/her transgressing any law or as a result of someone
else’s alleged violence? / Yes / No
If yes, please state circumstances of death.
C. DISPOSAL OF DEATH BENEFIT – DETAILS OF BENEFICIARY / CLAIMANT
Surname and initials
First names
Date of birth
ID number
Relationship to deceased
We will transfer the proceeds into your bank account directly. Please provide details below:
Name of bank
Branch name
Branch number
Type of account
Account number
Name of account holder
D. DISPOSAL OF FUNERAL BENEFIT- DETAILS OF BENEFICIARY / CLAIMANT
Surname and initials
First names
Date of birth
ID number
Relationship to deceased
We will transfer the proceeds into your bank account directly. Please provide details below:
Name of bank
Branch name
Branch number
Type of account
Account number
Name of account holder
E. DECLARATION BY BENEFICIARY / CLAIMANT
I, the undersigned warrant that I am legally entitled to receive the proceeds in terms of the said plan and that the estate
is solvent and has not been ceded, sequestrated or estranged in any way.
I declare that all information supplied herein is accurate and complete.
Signed at / Date / Y / Y / Y / Y / M / M / D / D
Signature of claimant
Signature of employer
NB: PLEASE
COMPLETE THIS
FORM IF DEATH IS
DUE TO UNNATURAL
CAUSES
Tel: 011 846 3717
Fax: 086 753 3843 / / Employer name/BTP no:
Member name and surname:
Member reference:
To be completed by the investigating officer at the specific police station where the incident was reported.
- Date, time and place of incident.
- Date, time and place of death.
- Magisterial district.
- Is there a suspicion that the deceased may have committed suicide?
- If ‘yes’, was a suicide note left?
- Was the insured life involved in a motor vehicle accident?
- Was the insured life
- If the driver, was he/she in possession of a valid driver’s licence?
- Was a blood alcohol test done?
- What were the results of the blood alcohol test?
- Was the insured life involved in an assault?
- Was the insured life assaulted during the performance of his/her duties?
- Was the insured life an innocent spectator?
- Was or will a court proceeding be held in this regard?
- Name of court
- Reference number of court/inquest proceedings
- Was or will criminal proceedings be instituted in this regard?
- What is the charge?
- Verdict, if known
- Name of police station where death/accident was reported
- Case reference number
- Investigating officer
If possible, please give a short description of the circumstances of the death/accident
Signature of Commissioner of Oaths/Justice of Peace
Name of Investigating Officer
Rank/Number
Contact number ‘s: Cell: / Work: / Code ( )