DEATH CLAIM FORM – Heirs Forms

DEATH CLAIM FORM.

DEATH CLAIM FORM
Name of Beneficiary:

Title:

Surname:

First Name:

Middle Name:

Policy Number:

Phone Number:

Product:

Relationship to the Deceased:

DETAILS OF THE DECEASED POLICY HOLDER
Name of Policyholder:

Title:

Surname:

First Name:

Middle Name:

Last Known Address:

Exact Location of Burial:

Place of Death:

Occupation at Death:

DETAILS FROM ATTENDING PHYISICAIN

Immediate Cause of Death

Gender of Deceased:

Height/Weight:

Date of Death:

Identification marks on Cadaver

Period of Aliment

From

To:

Please indicate if death was because
of Suicide, Homicide or Accident:

From what other disease or impairment has the deceased suffered and when?:

Additional Information:

DECLARATION FOR CLAIMANT

The undersigned hereby certies that he was the attending physician of the above deceased and that the statement are true and
complete to the best of his best knowledge and belief

Signature:

Date:

DECLARATION FOR PHYSICIAN

The undersigned hereby certies that he was the attending physician of the above deceased and that the statement are true and
complete to the best of his best knowledge and belief.

Name of Physician:

Title:

Surname:

First Name:

Middle Name:

Qualification:

Signature:

Date:

CHECK LIST

DOCUMENTS TO BE SUBMITTED:

1. Evidence or Proof of Age (if age was not admitted prior to death):

2. Original Policy Document:

3. Medical Certificate of Cause of Death):

4. Passport Photograph of Claimant/Beneciary; and

5. Proof of identity of Claimant/BeneciaryCopy of Authorization to Operate from Relevant Regulatory Bodies: