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Vineyard Claim Form
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Claim Number
POLICY HOLDER DETAILS
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Policy Number
*
Telephone Number
*
ID Number
*
Email Address
*
Name of Insured
*
Postal Address
*
CLAIMANT DETAILS (If different from policy holder)
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Full Name
*
ID Number
*
Telephone Number
*
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Email Address
Postal Address
DETAILS OF THE DECEASED PERSON
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First Name of Deceased
*
Last Name of Deceased
*
ID Number
*
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Age
*
Relationship Between Claimant And Deceased
*
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Date of Death
*
Cause of Death
*
Body At
*
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Venue of Funeral(Where Mourners Are Gathered)
*
Place of Burial
*
BENEFITS
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Plan Type
*
Type of Casket
*
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MOURNERS TRANSPORT
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YES
NO
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FOOD ALLOWANCE
*
PAYMENT METHOD
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Pay Cash
Bank Transfer
Mobile Transfer
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Bank Name
Bank Account Name
Bank Branch
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Bank Account Number
Mobile Number
DECLARATION BY CLAIMANT
I declare that the statements above are true and complete. In the event that this claim or any supporting document is found to be fraudulent, Vineyard Funeral Assurance reserves the right to proceed with appropriate action against me.
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Claimant Signature
Date
FOR OFFICE USE
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Claim verified by
Date
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Authorised by
Date
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Paid by (Finance)
Date
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