1. REPORT THE DEATH 2. GATHER AND COMPLETE THE …

HOW TO SUBMIT A DEATH CLAIM

75 Helen Joseph Street, Johannesburg, 2001

PO Box 6107, Johannesburg, 2000

[email protected]

1 of 3 How to submit a Death Claim Version No. 20181122

We understand that at a time like this, you need all the support you can get. That’s why we aim to process all valid claims as quickly as possible.

THESE ARE THE STEPS to follow when claiming from your benefit:

1. REPORT THE DEATH If the death has not been reported by the executor, bank, trust company, funeral parlour, etc., please report the

death to your nearest Home Affairs office, which will also provide you with the official death certificate.

2. GATHER AND COMPLETE THE REQUIRED DOCUMENTS COMPULSORY REQUIREMENTS

• Certified copy of death certificate.

• Copies of ID or passport for the deceased and beneficiary/beneficiaries or a copy of the birth certificate if

younger than 18.

• Proof of banking details for the beneficiary/beneficiaries or estate.

• We need a signed, dated and stamped statement from your bank that is not older than three months.

• A letter of executorship when the benefit is payable to the estate (in cases where there is no nominated

beneficiary).

• Certificate of Medical Attendant.

COMPLETE THE FORMS LISTED BELOW.

CLICK ON EACH LINE TO GET THE FORMS

• Notification of death form (Sample DHA 1663, formerly B11663)

• Old Mutual death claim form

• Old Mutual beneficiary form

If the beneficiary is a child:

1. An abridged birth certificate or a letter of guardianship.

2. Bank details in the name of the child.

CONTACT DETAILS:

CLAIMS SERVICE CENTRE0860 111 023 (08:00 - 18h00) [email protected]

HOME AFFAIRS0860 60 01 190www.home-affairs.gov.za

FINANCIAL ADVISERS0860 94 73 66 (weekdays 08:30 - 17:00)

https://www.oldmutuallife.co.za/media/102018_Death_Claim_Form_Life_Old_Mutual_Life_MBcgeIp.pdf

https://www.oldmutuallife.co.za/media/112018_Beneficiary_Claim_Form_Life_Old_Mutual_Life.pdf

2 of 3 Version No. 20181122How to submit a Death Claim

ADDITIONAL DOCUMENTS FOR UNNATURAL CAUSE OF DEATH (EXCLUDING FINAL EXPENSES, FINAL EXPENSES FAMILY BENEFITS)

• Old Mutual declaration by police

TERMINAL ILLNESS

If the life covered is diagnosed with a medical condition which, according to Old Mutual’s Chief Medical Officer,

will result in death within 12 months, the contracting party may request the payment of a Terminal Illness Benefit.

• Old Mutual terminal illness form

3. SEND THE DOCUMENTS TO Old Mutual Email: [email protected]

Post: Old Mutual Life, PO Box 6107, Johannesburg, 2000

We’ll let you know if we need any additional forms or documents

We would like you to get the right advice about investing your benefit payout and encourage you to speak to

one of our accredited financial advisers about your investment options.

If you don’t have a financial adviser, please send an email to [email protected] or call 0860 94 73 66.

4. FREQUENTLY ASKED QUESTIONS

Can I get a cash payout if I don’t have a bank account or can I nominate a third party’s bank account to receive the funds?

No, you will need to open a bank account in your own name in order to receive payment.

If a beneficiary lives outside of South Africa, how will funds be paid?

We will pay the funds into the beneficiary’s blocked or non-resident account. If you don’t have a blocked account, please contact your bank and apply for permission from the exchange control authorities.

When you have written permission from your bank, please submit a copy of the bank’s permission as well as the following documents to Old Mutual (refer to address details in point 3):• Fully completed Foreign Exchange Control questionnaire• Copy of your passport• Recent bank statement with an IBAN, SWIFT or SORT code

Once we receive permission from the Reserve Bank, the funds will be paid to you.

What is a DHA1663/BI1663 form and where do I get one?

It is an official notification of death form that you will get from the funeral parlour or the doctor who certified the Insured as deceased.

How do I certify a document? Make a copy of the document. Take the copy and the original to your nearest commissioner of oaths (there are commissioners of oaths at police stations, legal offices, banks and Old Mutual branches) to be certified. The commissioner will stamp, date and sign the copy of the document.

What must I do if no beneficiary was nominated or the deceased had no will?

• The family or interested parties must decide whom to appoint as the executor.• The appointed person has to collect the forms to apply for executorship from

the Master of the High Court.• When the court issues a letter of executorship, the executor can complete the

required forms and submit the claim documents.

https://www.oldmutuallife.co.za/media/102018_Police_Report_Life_Old_Mutual_Life_XJssZaB.pdf

https://www.oldmutuallife.co.za/media/112018_Terminal_Illness_Claim_Form_Old_Mutual_Life_zQ7sIFD.pdf

3 of 3 Version No. 20181122How to submit a Death Claim

What is a letter of executorship and a letter of authority and where can I get one?

• The person who has been appointed as the executor must take the death certificate to the Master of the High Court and apply for a letter of executorship or a letter of authority, depending on the size of the estate.

• A letter of executorship or authority enables the executor to act on behalf of the estate.

• It can take four to six weeks for the Master of the High Court to issue the letter.• A letter of executorship is needed if the value of the estate is more than R250 000.• A letter of authority is needed if the value of the estate is less than R250 000.

How do I obtain the bank details for the estate of the deceased?

• Once the letter of executorship or the letter of authority has been issued, the executor must go to a bank of his or her choice to open a bank account in the name of the estate. The executor will need to take along the death certificate, identity document of the deceased and a certified copy and the letter of executorship or authority.

• The executor will then have signing powers for that bank account.

There is a security cession on my policy or benefit, but the outstanding loan/bond has been settled. Do I need to include the cancelled cession to ensure any benefit is paid to the estate?

When the loan/bond was settled, the bank should have informed Old Mutual and the cession should have been removed. Please confirm with the bank.

If the cession has not been removed the bank should provide Old Mutual with a letter.

Must all estates be registered with the Master of the High Court?

Yes. For more information or to find your nearest office, go to www.justice.gov.za or phone +27 (0)12 315 1111.

What is the difference between natural and unnatural death?

• A natural death is primarily as a result of an illness or an internal malfunction of the body not directly influenced by external forces.

• An unnatural death is not properly describable as death by natural causes. It includes events such as accidents, drug abuse, execution or suicide.

REPUBLIC OF SOUTH AFRICA DHA-1663 ADEPARTMENT OF HOME AFFAIRS Page 1 of 3

NOTICE OF DEATH / STILL BIRTH[Births and Deaths Registration Act 51 of 1992]

[Regulations 11 and 14]

A. PARTICULARS OF THE DECEASED

1. Was this a death or a still birth? 1.1 Death 1.2 Still birth2. Identification of the deceased (tick one box):

2.1 The deceased was identified with an ID document / passport (if foreigner) produced by the family

2.2 Still born child

2.3 The features of the deceased do not seem to match the features on the ID document or passport of deceased

2.4 ID document or passport of the deceased was not presented. The deceased was identified through word of mouth

2.5 The deceased was already buried prior to the completion of this form

2.6 The deceased was unidentifiable: 2.6.1 Burnt 2.6.2 Decomposed 2.6.3 Other (specify)

2.6.4 DNA samples retrieved for identification purposes 2.6.5 Dental records taken for identification purposes

3. Date of Death / still birth Y Y Y Y M M D D

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Serial number

Instructions: Section A to be filled out by Authorised Medical Practitioner / Professional Nurse, who is responsible for examining the body to determine the cause of death . The Informant must verify, and where necessary, complete in full the personal particulars and other information of the deceased below.

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To be completed in full and submitted at the Department of Home Affairs' office by the informant or authorised funeral undertaker. The form to be completed in black ink with BLOCK LETTERS. Please mark with the CORRECT box, where required. All fields are COMPULSORY. Incomplete applications and applications that are not legible may be considered invalid. (Note: The fingerprints of the deceased, the informant and the undertaker must be taken by the undertaker)

4.1 Place of Death/still birth (City/Town/Village)

4.2 Province of Death/still birth

5. Place of Registration of Death / still birth

6. If death occurred within 24 hours after birth, number of hours alive 7. Home telephone no.

8. Identity No. (Passport No. if foreigner) 9. Age at last birthday if DOB is unknown

10. Date of Birth if there is no ID number Y Y Y Y M M D D 11. Gender 11.1 Male 11.2 Female 11.3 Indeterminable

12. Surname

13. Previous / Maiden Surname

14. Forenames

15. Usual* Residential Address: Street

Town

Province Postal code

16. Citizenship

16.1 Place of Birth (City / Town / Village)or Country of Birth, if abroad

16.2 Province of Birth

17. Marital Status of the deceased 17.1 Single 17.2 Married 17.3 Widowed 17.4 Divorced

20. Type of business / industry:

21. Was the deceased a regular** smoker five years ago? (mark with a ) 21.1 Yes 21.2 No 21.3 Do not know 21.4 Not applicable (minor)

* Where the deceased lived on most days. **Smoking tobacco on most days.

3. Manufacturing

4. Electricity, gas andwater supply

5. Construction1. Agriculture, hunting, forestry and

fishing

6. Wholesale and retail trade; repair of

motor vehicles, motor cycles and

personal and household goods;

hotels and restaurants

7. Transport, storage and communication

Gr 9 Form 2

None

8. Financial intermediation, insurance, real

estate and business services

9. Community, social and personal services

households, exterritorial

organisations, representatives of

foreign governments & other activities not adequately defined

Unknow

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Gr 1Gr R Gr 2 Gr 3 Gr 6 Gr 7Gr 4 Gr 10 Form 3 NTC 1

Gr 11 Form 4 NTC 2

Gr 12 Form 5 NTC 3

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Gr 8 Form 1

Gr 5 Univ Tech

2. Mining andquarrying

19. Usual occupation of deceased (type ofwork done during most of working life)

18. Education level of deceased, (Specify only the highest classcompleted)

(mark with a )

(mark with a

G.P.-S. 09/09

)10. Private

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SAMPLE - DO NOT USE




B. CERTIFICATE BY ATTENDING MEDICAL PRACTITIONER / PROFESSIONAL NURSE Instructions: Section B to be filled out by the same Medical Practitioner / Professional Nurse who completed Section A.

22.1 I, the undersigned, hereby certify that the deceased named in Section A, to the best of my knowledge and belief, died solely and exclusively due to Natural Causes

22.2 I, the undersigned, am not in a position to certify that the deceased died exclusively due to Natural Causes

Particulars of the Medical Practitioner / Professional Nurse who filled out the form: 23. HPCSA Registration No.

24. Surname

25. Forenames

26. Name of Health Facility / Practice 27. Facility / Practice No.

28. Business Address: Street

Town Province

Telephone No. (Office) Postal Code

Place signed

Date signed Y Y Y Y M D Si t

I, the undersigned, hereby certify that I examined the body of the deceased named in section A and declare that the deceased, to the best of my knowledge and belief, died solely and exclusively due to natural or unnatural causes as indicated on paragraph 22 and in case this is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.)

Serial number

Office stamp of health facility or practice

BARCODE


Date signed Y Y Y Y M D Signature

C. CERTIFICATE BY MEDICAL PRACTITIONER/ FORENSIC PATHOLOGISTInstructions: Section C to be filled out by Medical Practitioner or Forensic Pathologist, who is conducting medico-legal investigation of death.

30.1 Natural 30.2 Unnatural 30.3 Under investigation

31. Date of Post-mortem Y Y Y Y M M D D

32. Name of Medico-legal Mortuary / Mortuary 33. Mortuary No.

34. Mortuary Reference Number of Deceased

35. SAPS Case No. 36. Name of Police Station

Particulars of the Medical Practitioner / Forensic Pathologist who filled out the form:

37. Surname

38. Forenames

39. Business Address Street

Town Province Postal Code

Telephone No. (Office)

Place signed

Date signed Y Y Y Y M M D Signature

D. PARTICULARS OF INFORMANT

40. Identity No. (Passport No. if foreigner) 41. Date of Birth Y Y Y Y M M D D

42. Citizenship

44. Forenames

45. Residential Address: Street

Town

Province Postal Code

Telephone No. (Home) Cellphone No.

46. The Deceased is my: 46.1 Parent 46.2 Spouse 46.3 Child 46.4 Other, Specify

Signature Date signed Y Y Y Y M M D D Place signed

Office stamp of mortuary

29. I, the undersigned, hereby certify that a medico-legal investigation of death has been conducted on the body of the person whose particulars are given in Section A and that the body is no longer required for the purpose of the Inquest Act, 1959 (Act No. 58 of 1959) and the cause of death is:

I, the undersigned, hereby certify that the identity of the deceased mentioned in section A is to the best of my knowledge and belief true and correct in case it is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.)

43. Surname

I, the undersigned, hereby certify that I examined the body of the deceased named in section A and the deceased, to the best of my knowledge and belief, died solely and exclusively due to natural or unnatural causes as indicated on paragraph 29 and in case this is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.)

Instructions: Section D to be completed by informant. Informant is responsible for certifying the identity of the deceased.

G.P.-S. 09/09

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DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA


HPCSA Registration No.




E. PARTICULARS OF FUNERAL UNDERTAKER

47. Name of Funeral Parlour

48. DHA Designation No. 49. Company Reg. No.

50. SARS Reg. No. (Income tax reference no.)

Details of Funeral Undertaker or Authorised Representative

51 Id tit N (P t N if f i )

Serial number

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ker

Instructions: Section E to be completed by Funeral Undertaker. The undertaker must take his or her finger print, the finger print of the deceased and the informant. Authorised Funeral Undertaker or Informant may submit the completed form to the nearest Home Affairs office.

BARCODE


51. Identity No. (Passport No. if foreigner)

52. Surname

53. Forenames

54. Business Address Street

Town

Province Postal Code

Telephone No. (Office) Cellphone No.

55. Date of collection of corpse Y Y Y Y M M D D 56. Date of Cremation (if applicable) Y Y Y Y M M D D

57. Place of Burial (City / Town / Village) Province

58. Date of Burial Y Y Y Y M M D D 59. Grave No. (if available)

Name of person who collected the deceased:

60. Identity No. (Passport No. if foreigner)

61. Surname

62. Forenames

Place signed

Date signed Y Y Y Y M M D SignatureF. FOR OFFICIAL USE ONLY

Registration of death approved, DHA-1663 received by (particulars of DHA official):

63. Identity No.

64. Surname

65. Forenames

66. Persal No.

Documents included with this notice: Copy of the deceased's ID Copy of ID document of the informant

DHA - 6 (if applicable) DHA - 1680 (if applicable)

DHA-1663 was submitted by: Informant Funeral Undertaker

Office stamp of funeral undertaker

Office stamp of DHA

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D

BENEFICIARY CLAIM FORMFOR DEATH/ACCELERATED FUNERAL DEATH BENEFIT

1 of 2 Version No. 20181121



[email protected]

Beneficiary Claim Form

Policy number:

To be filled in by the beneficiary or beneficiaries• Please print in block letters using black or blue ink.• Each beneficiary must fill in this form. If there is more than one beneficiary, each beneficiary must fill in a separate form.• If you are also the contact person for a claim, please fill in the CONTACT FORM FOR DEATH/ACCELERATED FUNERAL DEATH BENEFIT.• To find out exactly what documents you need to provide us with for your claim, please ask for our HOW TO SUBMIT A DEATH CLAIM information page.

1. BENEFICIARY DETAILS Title Mr: Ms: Mrs: Other: Initials:

First names: Surname:

ID number:

Relationship to the deceased: Family member: Executor of estate:

Other: (please explain)

Contact numbers:

Work: Home:

Fax: Cellphone:

Email address:

Residential address if different to postal address:

Postal address:

2 of 2 Beneficiary Claim Form Version No. 20181121

2. BENEFICIARY BANK DETAILSName of bank:

Name of account holder:

Branch name: Branch code:

Account number: Account type: Current Savings Transmission

Swift/BAN/Sort code: (for foreign bank accounts only)

• We pay all claims by EFT into each beneficiary’s bank account.

• We don’t pay in cash or by cheque.

• If you don’t have a bank account, you need to open one.

• The bank account must be in your name.

• We do not pay into third party accounts.

• If you are a minor, you still need a bank account in your name.

• We need you to apply for permission from the South African Reserve Bank before we can pay into a foreign bank account.

• We are not responsible if we pay into an incorrect bank account based on incorrect banking information you gave us.

3. DECLARATION OF CONTACT PERSONI confirm that all the information provided on this form is true and accurate to the best of my knowledge. I give Old Mutual consent to confirm the information provided with any other source.

Signed at: the day of 20

Signature of Beneficiary:

PROTECTION OF PERSONAL INFORMATION (PPI) The Old Mutual Group would like to offer you on-going financial services and may use your personal details to provide you with information about products or services that may be suitable to meet your financial needs. If you prefer not to receive such information and financial services, SMS your ID number to 45600.

To view our full privacy notice and to exercise preferences, visit our website on www.oldmutual.co.za

TERMINAL ILLNESS CLAIM FORM



[email protected]

1 of 3 Version No. 20181121Terminal Illness Claim Form

1. TO BE COMPLETED BY THE CLAIMANT

Title Mr: Ms: Mrs: Other: Initials:

Surname/ Name of institution:

Policy number:

First names/Contact person:

Previous surname(if applicable):ID number/Institutionregistration number:

Country of issueof passport:

Passport number:

Date of birth: Age at next birthday:

Are you a South African resident?

Gender: Male Female:

Yes NoIncome tax number:

Residential address/Physical addressof institution:

Postal address:

Telephone:

Email address:

Marital status: Single Married Divorced Widowed Correspondence Language: English Afrikaans

Race: Black Indian Coloured White

The Financial Services Charter requires life insurance companies to report on the racial spread of their client bases. Please assist us to fulfil our obligations under the Charter by indicating to us the race group to which you feel you belong. This information will be used only for determining (and reporting on) the racial spread of our client base.

(W): (H):

Fax: Cell:

(where no South African ID number is available)

GUIDELINES ON SUBMISSION OF A CLAIM:• Please print in block letters using black or blue ink.• Section 1 – Must be completed and signed by the claimant/Contracting Party where appropriate.• Section 2 – Must be completed and signed by the claimant’s attending doctor.

IMPORTANT: PLEASE CONTINUE PAYING YOUR MONTHLY CONTRIBUTIONS TO AVOID BENEFITS CEASING.

CONTRACTING PARTY DETAILS

Y Y M DY Y M D

2 of 3 Terminal Illness Claim Form Version No. 20181121

Name of bank:

Branch name:

Account holder’s name:

Account number:

Accountholder relationship: Own account Joint account 3rd Party account

PROTECTION OF PERSONAL INFORMATION (PPI) NOTICEThe Old Mutual Group would like to offer you ongoing financial services and may use your personal information to provide you with information about products or services that are suitable to your financial needs. If you do not want to receive such information or financial services, SMS your ID number to 45600.

We may use your information or obtain information about you for the following purposes:• Underwriting• Assessment and processing of claims• Credit searches and/or verification• Claims checks (ASISA Life and Claims Register)• Fraud prevention and detection• Market research and statistical analysis• Audit and record keeping purposes• To comply with legal and regulatory requirements• Verifying your identity• Sharing with service providers we engage to process information on your behalf.

You may access the information that we hold about you and ask us to correct any errors or delete the information we have about you. To view our full privacy notice and to exercise preferences, visit our website on www.oldmutual.co.za.

I irrevocably authorise:(a) Old Mutual to obtain information, from any person, which is needed to assess claims;(b) the concerned person (in a) to give Old Mutual the required information;(c) Old Mutual to share obtained information, which includes information contained in any pertinent document or contract, with other insurers and the Life Offices’ Association of South Africa (LOA), to assess risks or claims;(d) the LOA to give any such information received from Old Mutual to other insurers to assess risk or claims. Any information may, under this authorisation, be obtained or given at any time, even after my death, and in such detail, or in such abbreviated or coded form, as Old Mutual or the LOA may from time to time decide.

I understand that my right to privacy is curtailed to the extent permitted by me in this authorisation. This information may be used by Old Mutual to determine the validity of this claim. By signing below, I certify that I agree to the prepayment of the death benefits under the abovementioned plan(s). I understand that if my request for this prepayment is approved, the full cover amount of the death benefit(s) will be payable as full and final settlement of these benefit(s). I understand that the benefit(s) will cease after this payment.

Branch code:

CONTRACTING PARTY DETAILS

DECLARATION

Signature of claimant: Date: Y Y M DY Y M D

3 of 3 Terminal Illness Claim Form Version No. 20181121

I certify that I have personally attended the patient and that all the foregoing statements are correct to the best of my knowledge.

Initials: Surname:

Qualifications:

Address:

Practice number:

Name of hospital:

Address of hospital:

Telephone no: Fax no:

Signed at: the day of 20

Signature of medical attendant:

Date:

2. TO BE COMPLETED BY THE ATTENDING DOCTOR

Date of first visit:

Diagnosis:

A. Present condition Please provide us with sufficient detail of the claimant’s present condition to support that a reasonable assessment of the life expectancy of the claimant is less than twelve months.

B. General1. Please indicate the terminal illness from which the claimant is suffering, with the appropriate international staging of the disease, where applicable. To support the claim, please provide us with copies of all tests, investigations and reports in your possession.

2. If the claimant is suffering from Carcinoma, please provide us with a copy of the histology report and a detailed staging of the disease to enable Old Mutual to arrive at the appropriate decision.

3. If the claimant is HIV positive, please advise the current stage.

Date of last visit:

A terminal illness is defined as a medical condition that, with reasonable medical certainty in the opinion of Old Mutual’s Chief Medical Officer, will result in the death of the life assured within twelve months of the date medical evidence to that effect is provided.

Y Y M DY Y M D Y Y M DY Y M D

Y Y M DY Y M D