Statement on death - nbcei

<strong>Statement</strong> on death
A fully completed declaration, as well as all required documents, is
a prerequisite for the prompt settlement of a claim.
E m p l o y e e B e n e f i t s
Licensed Financial Services Provider
A. Particulars of the fund/scheme
Name of the fund/scheme:
Name of branch/participating employer:
Code (if known)
(“Scheme” means a separate arrangement which provides for group life or disability insurance offered outside the fund.)
B. Particulars of deceased
Full names and surname:
Date of birth:
Gender:
Date of death:
If the cause of death is “natural or unnatural” please provide more details.
Residential address of the deceased immediately before his/her death:
Membership number:
Occupation:
Marital status:
Cause of death:
Pay-sheet number:
Annual pensionable remuneration: (i) On fund/scheme anniversary immediately prior to death: R
(ii) On date of death: R
(iii) One year prior to date of death: R
Sum assured (spouse’s pension, children’s pension and refund of member’s contributions excluded):
The last deduction of member’s contributions from the deceased’s salary will be/has been made on
If you furnish Sanlam Employee Benefits annually with a return of members’ contributions made, please fill in the amount of the member’s
contributions made as from your last return until the date of the last deduction:
Last date of active service:
Was the deceased at date of death absent from service without remuneration or with reduced remuneration (Yes/No)
If YES, state full particulars:
C. Method of payment
1. Particulars of beneficiary: Particulars of beneficiary must be indicated in the trustees’ resolution.
2. Particulars of deceased
Tax reference number
R
Revenue office at which last tax return was submitted
Highest average salary actually earned by the employee during any five consecutive years in the service of the employer while he/she was
a member of the fund:
R
Year (ccyy) Salary Average for the 5 years or lesser period if the
employee was employed for a lesser period
R
R
R
Twice the salary for the12-month period
Immediately preceding death
R
R
R
R
R
“Salary” referred to above, includes any amount received or amounts
received annually under a contract of service, as well as cost of living
allowances, commission, share if profits, etc., but excludes occasional
bonuses or fees according to the discretion of the directors or
employer.
3. Amount owing to employer, which may be deducted from the death benefits in terms of the Rules of the fund. (NB: The fund will
contravene the Pension Funds Act if an amount is deducted from the death benefit which does not fall clearly within the restriction, as
stated in the Rules.)
Debt: R
E1615
Sanlam 07/2006

D. Documents required by Sanlam Employee Benefits
(i)
(ii)
(iii)
(iv)
Original certified copy of death certificate.
Birth certificate.
Original certified copy of identity document.
Trustees’ resolution (including particulars of beneficiary)
(v) Payment details of beneficiary.
Notes:
(a) The following requirements must be met in order for a document to be considered as a certified document:
The Commissioner of Oaths’:
- Full name and surname
- Business address
- Capacity
(b) The following is required in respect of trustees’ resolutions:
- An extract of minutes of the trustee meeting during which the decision was taken, - and/or
- A letter from the Chairperson/Principal officer/Secretary confirming the decision by the trustees at a trustees’ meeting.
E. Spouse’s and Children’s pension
(Only to be completed if the fund makes provision for such benefits.)
Qualifying spouse
Full Christian names:
Date of birth
Date of marriage:
Address:
Qualifying child(ren)
Full Names Gender Date of birth
Payment of spouse’s and/or children’s pension
Instalments are paid into the beneficiary’s bank account.
Name of bank:
Type of account:
Address of bank:
Branch code:
Account number:
(In the case of more than one beneficiary, the above-mentioned details must be provided in respect of all the beneficiaries.)
Documents required by Sanlam Employee Benefits
1. Original certified copy of proof of age of qualifying spouse/children.
2. Original certified copy of marriage certificate of qualifying spouse.
3. Details of Trust (if applicable).
F. Declaration and certification
We, the undersigned, hereby declare on behalf of the fund/scheme that the person mentioned in section B has died and that he/she did
qualify for membership of the fund/scheme at date of death. We also declare that the above-mentioned information is complete and
correct and we recommend that the claim be admitted.
Signed at
on (dd/mm/ccyy)
On behalf of the fund/scheme
1. (Capacity)
2. (Capacity)
E1615
Sanlam 07/2006