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DEPENDANTS DETAILS UPDATE a Spouse b Children Signature Workerslife is an authorised Financial Services Provider in terms of the FAIS Act FSP no. 392 Company Reg. no. 1993/004296/06 Sex ID No. Date of Birth Claim Form Continued 5. DETAILS OF FUNERAL PARLOUR Name of Undertaker Branch Town Contact Person Contact Numbers 6. Claim Form Fax Number 0861 530 530 Call Line 0861 520 520 1. CLAIMANT S DETAILS Surname Full Names ID. No Relationship to the Deceased Residential Address Code Postal Address Tel No* W Cell No* Fax No* Are you the appointed Yes Beneficiary No Mark with X 2. DECEASED S DETAILS Date of Birth D M Y 3. EMPLOYER Complete only if the deceased is the Member Name of Employer Employer s Address Department Salary No 4. DEPENDANTS DETAILS UPDATE a Spouse b Children Signature Workerslife is an authorised Financial Services Provider in terms of the FAIS Act FSP no. 392 Company Reg* no. 1993/004296/06 Sex ID No* Date of Birth Claim Form Continued 5. DETAILS OF FUNERAL PARLOUR Name of Undertaker Branch Town Contact Person Contact Numbers 6. BANK DETAILS OF CLAIMANT Account Holder Name of Bank Branch Code Account No Signature of the Claimant Date NB. A Certified Bank Statement to verify Claimant s Bank Details must be attached and must reflect the Name of the Claimant as well as the bank account number. Claim Form Fax Number 0861 530 530 Call Line 0861 520 520 1. CLAIMANT S DETAILS Surname Full Names ID. No Relationship to the Deceased Residential Address Code Postal Address Tel No* W Cell No* Fax No* Are you the appointed Yes Beneficiary No Mark with X 2. No Relationship to the Deceased Residential Address Code Postal Address Tel No* W Cell No* Fax No* Are you the appointed Yes Beneficiary No Mark with X 2. DECEASED S DETAILS Date of Birth D M Y 3. EMPLOYER Complete only if the deceased is the Member Name of Employer Employer s Address Department Salary No 4. DECEASED S DETAILS Date of Birth D M Y 3. EMPLOYER Complete only if the deceased is the Member Name of Employer Employer s Address Department Salary No 4. DEPENDANTS DETAILS UPDATE a Spouse b Children Signature Workerslife is an authorised Financial Services Provider in terms of the FAIS Act FSP no. 392 Company Reg* no. 1993/004296/06 Sex ID No* Date of Birth Claim Form Continued 5. DETAILS OF FUNERAL PARLOUR Name of Undertaker Branch Town Contact Person Contact Numbers 6. BANK DETAILS OF CLAIMANT Account Holder Name of Bank Branch Code Account No Signature of the Claimant Date NB. BANK DETAILS OF CLAIMANT Account Holder Name of Bank Branch Code Account No Signature of the Claimant Date NB. A Certified Bank Statement to verify Claimant s Bank Details must be attached and must reflect the Name of the Claimant as well as the bank account number. Claim Form Fax Number 0861 530 530 Call Line 0861 520 520 1. CLAIMANT S DETAILS Surname Full Names ID. No Relationship to the Deceased Residential Address Code Postal Address Tel No* W Cell No* Fax No* Are you the appointed Yes Beneficiary No Mark with X 2. DECEASED S DETAILS Date of Birth D M Y 3. EMPLOYER Complete only if the deceased is the Member Name of Employer Employer s Address Department Salary No 4.

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