Group Funeral Policy Claim Form
1. Policy Details
Policy Number
Policyholder Name
Group/Employer Name
2. Deceased Member Details
Full Name
Date of Birth
Date of Death
Relationship to Policyholder
Membership/Employee Number
3. Claimant Details
Claimant Name
Contact Number
Address
Relationship to Deceased
4. Bank Details for Payout
Bank Name
Account Holder
Account Number
Branch Code
5. Supporting Documents
Death Certificate (attach copy)
Certified Copy of ID (Deceased and Claimant)
Proof of relationship
Bank statement/cancelled cheque
Policy document (if available)
6. Declaration
I declare that all information provided is true and complete.
Claimant Signature
Date