an authorised Financial Service Provider in terms of the FAIS Act ( License No. 2409)
Liberty Centre, 1 Ameshoff Street, Braamfontein, 2001 P O Box 2094, Johannesburg 2000
Liberty Sentrum, Ameshoffstraat 1, Braamfontein 2001 Posbus 2094, Johannesburg 2000
Tel: (011) 408-2999 Fax/Faks: (011) 408-2158
E-mail address:
FAMILY (FUNERAL) BENEFITS NOTIFICATION
1. MEMBER DETAILSScheme name / Scheme no
Employer name / Employee/Payroll ref no
Member’s ID no / Membership no
Member’s full name
(as per ID document) / Surname:
Forenames:
2. CLAIM DETAILS
Deceased’s Full Names
(if not the Member) / Surname:
Forenames:
Cause of Death / Date of death
Relationship of Deceased to Member
(if not the Member)
In regard to the deceased, please tick one of the following blocks, if applicable:
0 – 6 years 7 – 13 years 14 – 21 years 21 – 25 years studying over 21 years handicapped
(proof required) (proof required)
3. PAYEE DETAILS
Schemes for which contributions are paid by direct debit
- Please refund electronically to the employer’s account
Schemes for which contributions are not paid by direct debit
- Please issue a cheque to the employer (We reserve the right to charge a handling fee)
- Please refund electronically to the employer’s account, details below:
Name of account holder
Name of bank
Name of branch / Branch no
Account no / Type of account
(An ORIGINAL cancelled cheque or ORIGINAL account statement must be attached for verification purposes, otherwise processing
could be delayed)
NOTE:
- If you request a cheque, you indemnify Liberty Corporate and the Scheme should the cheque be stolen or otherwise go missing.
Please note that in the event of any modification or variation of this standard form Liberty Corporate will regard this form as being
invalid and of no force and effect. Do not sign blank or incomplete forms.
LCB033/1010
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4. DOCUMENTARY REQUIREMENTS(a) Proof of age of the deceased (original or certified copy) / ENCLOSED
(b) Death Certificate (original or certified copy) / ENCLOSED
(c) Identification of Dependants/Nomination of Beneficiary form (if available) / ENCLOSED
(d) Certified proof of relationship (if deceased is not the member) / ENCLOSED
ie. birth or marriage certificate or an affidavit signed in the presence of a commissioner of oaths.
5. EMPLOYER’S DECLARATION
It is declared that the member commenced employment on / and was actively in our
service at the date benefits are claimed, and that the deceased satisfied the conditions to be an eligible member/spouse/child as
the case may be.
We hereby declare that the above information and answers are true and correct.
AUTHORISED SIGNATORY / DATE
Company stamp
Please note that in the event of any modification or variation of this standard form Liberty Corporate will regard this form as being
invalid and of no force and effect. Do not sign blank or incomplete forms.
LCB033/1010
Page 1 of 2