Policy Details:

Plan Type*

Policy Number*

Details of the Principal insured:

Name & surname*

ID number*

Details of the Deceased:

Name & surname*

ID number*

Relation*

Principal Insured

Spouse

Common Law Spouse

Child

Extended Family Member

Cause of Death*

Natural

Unnatural

Suicide

Date of Birth*

MM slash DD slash YYYY

Entry Date*

MM slash DD slash YYYY

Date of Death*

MM slash DD slash YYYY

Please specify exact cause of death*

Indicate the type of claim amount:

Funeral Life Hero*

Single

Family

Benefit Amount*

Details of the Nominated Beneficiary:

Name & surname*

Contact number*

ID Type*

RSA

Other

ID number*

Citizenship if not South African*

Country of Birth*

Occupation*

Employer*

Relationship to the Principal Insured*

Email address*

Address*

Postal code*

Claimant Declaration

I hereby waive any right to privacy and authorise the Insurer (or its appointed Administrator):
• to obtain from any doctor, registered healthcare practitioner, hospital, medical institution, police station, insurance company or any other person or entity, whom I hereby authorise to give and to disclose, any information which the Insurer requires or deems necessary to facilitate the assessment of the risks and the consideration of this claim for benefits under this Policy arising from this claim application, and;
• to disclose any insurance information (provided by me or on my behalf to any other insurance company, either directly or through a database operated by or for Insurers as

a group, at any time and in such detailed, abbreviated or coded form as may from time to time be decided by the Insurer or by the operators of such database; and
• to verify any information provided against other sources or databases;
• to disclose information regarding a specific policy, owner or life insured to any persons or institution provided that the Insurer considers such disclosure necessary in order to assess this claim; and
• where required through the operation of law, to disclose information regarding a specific policy, owner or life insured to regulatory and government agencies.

Name & surname*

Place*

Date*

MM slash DD slash YYYY

Signature*

Prior Funeral Cover:

Is this Policy a replacement policy for existing funeral cover?*

Yes

Was the prior policy cancelled and replaced with this one?*

Yes

Were all lives to be covered listed on the alternate policy?*

Yes

Had the waiting period for natural death already expired on the alternate policy?*

Yes

Please provide us with:

Proof of alternate cover

Max. file size: 512 MB.

Confirmation from the insurer that the policy was paid up to date

Max. file size: 512 MB.

Proof of the cancellation

Max. file size: 512 MB.

Name & surname*

Place*

Date*

MM slash DD slash YYYY

Signature*

Processing of Personal Information:

2. Law enforcement and fraud prevention agencies and other persons tasked with the prevention and prosecution of crime;
3. Regulatory authorities, industry ombudsmen, governmental departments, local and international tax authorities, and other persons that we, in accordance with the Applicable Laws, are required to share your Personal Information with; and
4. Credit Bureau’s.

You acknowledge that any Personal Information supplied to Us in terms of this Claim is provided according to the Applicable Laws. Unless consented to by yourself, We will not sell, exchange, transfer, rent or otherwise make available your Personal Information to any other parties and you indemnify Us from any claims resulting from disclosures made with your consent. Such Personal Information provided (voluntarily, unconditionally and specifically) will be utilised by Us or by any appointed third parties, on our behalf, and will be kept for such period as legislated according to the Applicable Laws. You understand that if We have utilised your Personal Information contrary to the Applicable Laws, you have the right to lodge a complaint with Guardrisk . Should Guardrisk not resolve the complaint to your satisfaction, you have the right to escalate the complaint to the Information Regulator.

Your privacy is of utmost importance to Us. We will take the necessary measures to ensure that any and all information, including Personal Information (as defined in the Protection of Personal Information Act 4 of 2013) provided by you or which is collected from you is processed in accordance with the provisions of the Protection of Personal Information Act 4 of 2013 and further, is stored in a safe and secure manner and kept for the period prescribed by the Applicable Laws. You hereby agree to give honest, accurate and up-to-date Personal Information which may be used for the following reasons:
1. to establish and verify your identity in terms of the Applicable Laws;
2. to enable Us to fulfil our obligations in terms of this Claim;
3. to enable Us to take the necessary measures to prevent any suspicious or fraudulent activity in terms of the Applicable Laws; and
4. reporting to the relevant Regulatory Authority/Body, in terms of the Applicable Laws.

We may share your information for further processing with the following third parties, which third parties have an obligation to keep your Personal Information secure and confidential: 1. Payment processing service providers, merchants, banks and other persons that assist with the processing of any benefit payable;

Name & surname*

Place*

Date*

MM slash DD slash YYYY

Signature*

Nominated Beneficiary Authorisation:

I, the above nominated beneficiary, hereby appoint the 3rd party below as the person/entity to whom the Insurer must pay the benefit due upon successful validation of this claim. I also hereby indemnify Life Hero against all/any claim by any party for any benefit or money, loss of damages incurred or suffered, in respect of, or caused by any representation made by me to Life Hero and/or the payment by Life Hero to the below mentioned person/entity of any benefit in respect of the claim lodged.

Name & surname*

ID number*

Contact number*

Relationship to the Principal Insured*

Name of entity*

Registration number*

Signature of nominated beneficiary consenting to the above*

Banking Details:

Account holder name*

Name of Bank*

Branch code*

Branch*

Account number*

Type of Account*

Policy Continuation / Cancellation Option:

Note: if the claim is for the Principal Insured, the surviving Spouse has the option to continue with the Policy. Please indicate the option chosen.

Continue with the policy*

Yes

Name & surname*

ID number*

Contact number*

Documents to be submitted to Life Hero:

Please select the documents you would like to upload

Claims for Funeral

Life Hero Claim Form

Certified copy of ID document: Deceased

Certified copy of death certificate

DHA 1663 / DHA 1680

Marriage Certificate

Police Report in the event of a motor vehicle accident. Where the death is under investigation or in the event of suicide

Birth / Baptism Certificate

Beneficiary / Claimant ID document

Proof of bank details / Bank statement of Beneficiary

Certified copy of Mother’s ID document

An unabridged death certificate issued by the Hospital (usually handwritten)

If a student and dependent: registration at tertiary institution stating full time student and dependent

Doctors letter of confirmation in the event of a mentally or physically disabled child

Doctors letter of confirmation in the event of a stillborn birth

Claims for Funeral*

Max. file size: 512 MB.

Life Hero Claim Form*

Max. file size: 512 MB.

Certified copy of ID document: Deceased*

Max. file size: 512 MB.

Certified copy of death certificate*

Max. file size: 512 MB.

Marriage Certificate*

Max. file size: 512 MB.

DHA 1663 / DHA 1680*

Max. file size: 512 MB.

Police Report*

Max. file size: 512 MB.

Birth / Baptism Certificate*

Max. file size: 512 MB.

Beneficiary / Claimant ID document*

Max. file size: 512 MB.

Proof of bank details / Bank statement of Beneficiary*

Max. file size: 512 MB.

An unabridged death certificate issued by the Hospital*

Max. file size: 512 MB.

Certified copy of Mother’s ID document*

Max. file size: 512 MB.

If a student and dependent: registration at tertiary institution stating full time student and dependent*

Max. file size: 512 MB.

Doctors letter of confirmation in the event of a mentally or physically disabled child*

Max. file size: 512 MB.

Doctors letter of confirmation in the event of a stillborn birth*

Max. file size: 512 MB.

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Let’s step up for you

Claim Form - Funeral Claim

Policy Details:

Details of the Principal insured:

Details of the Deceased:

Indicate the type of claim amount:

Details of the Nominated Beneficiary:

Claimant Declaration

Prior Funeral Cover:

Please provide us with:

Processing of Personal Information:

Nominated Beneficiary Authorisation:

Banking Details:

Policy Continuation / Cancellation Option:

Documents to be submitted to Life Hero:

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