Claim Registration
Submitted By
(Required)
Submitted By
Ashira Sackstein
Bathabile Moya
Jay Baum
Makgotso Matsepe
Matthew Arnold
Nkateko Ndou
Nobulumko Colleen Sigabi
Noluthando Nkomo
Phumza Ngcobo
Ramulutsi Mogale
Regan Anthony
Shanice Lawrence
Thandeka Mkhwanazi
Vivian Molefe
William Botha
Policy Number
(Required)
Claim Number
(Required)
Insured & Claimant Details
Insured Name
(Required)
Insured Surname
(Required)
Insured ID Number
(Required)
Claimant Name
(Required)
Claimant ID Number
(Required)
Insured Relationship
(Required)
Insured Relationship
Main life
Spouse
Parent 1
Parent 2
Parent 3
Parent 4
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Extended family 1
Extended family 2
Extended family 3
Extended family 4
Extended family 5
Extended family 6
Extended family 7
Extended family 8
Extended family 9
Not insured
Who is the claimant to the main life?
Beneficiary Details
Beneficiary Name
(Required)
Beneficiary ID Number
(Required)
Premium Payer Details
Third Party Payer
(Required)
No
Yes
Third Party Relationship
(Required)
Select…
Spouse / Partner / Girlfriend / Boyfriend
Parent
Step-Parent
Parent-In-Law
Child
Step-Child
Child-In-Law
Sibling
Step-Sibling
Sibling-In-Law
Uncle / Aunt
Cousin
Neice / Nephew
Grandparent
Unknown
Who is the premium payer to the main life?
Claim Details
Claim Opened
(Required)
YYYY dash MM dash DD
Date of Event
(Required)
YYYY dash MM dash DD
Benefit Description
(Required)
Benefit Description
Death
Disability
Illness
Temporary Income
Permanent Income
Death Type
(Required)
Death Type
Natural death
Accidental death
Subtype
(Required)
Sum Assured
(Required)
Please enter a number greater than or equal to
1
.
Event City
(Required)
Event Country
(Required)
Event Country
RSA
Outside RSA
N/A
Event Province
(Required)
Event Province
Kwazulu Natal
Eastern Cape
Gauteng
Northern Cape
Free State
Western Cape
Mpumalanga
North West
Limpopo
Comment
