Death Claim Form
National Bargaining Council for the Road Freight and Logistics Industry
Your Road Freight Partner.
This form is required in order for Insurers to assess a possible claim. Comple on of this form by the Insured or an
Insured Person does not in any way limit liability.
Only once we have received a fully completed claim form will we the incident being claimed for.
Any cost incurred in the comple on of this form will be the responsibility of the Principal Member or the Insured
Person.
The following informa on should be provided as and when it becomes available:
A Cer fied copies of the abridged and final death cer ficates;
B A cer fied copy of the post mortem report;
C A cer fied copy of the full inquest report including all witness statements pertaining thereto;
D The police accident report if the death was the result of a motor vehicle accident;
E The police sta on and reference number if the death is the subject of a criminal inves ga on.
F BI 163 (no fica on of death form, indica ng cause of death)
Fax Number: 086 560 4945
Email: funeralclaims@nbcrflihealth.co.za
SECTION 1: GENERAL
Name of Principal Member:
Membership Number:
Full Name
Occupa on:
Date of Birth:
Date of Incident:
Time:
Place:
Give a detailed descrip on of how the Incident happened:
If in the event of a Motor Vehicle Accident, please a ach copies of the Police Accident Report, Road Accident
Report and Witness Statements (if any)
Residen al Address:
Postal Code:
Postal Address:
Postal Code:
Contact Numbers: Office
Home:
Beneficiary's Banking Details:
Bank:
Branch:
Code:
Type:
Account Holder:
Account No:
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Affinity Health (Pty) Ltd Reg. No. 2011/101096/07, Directors: M.Hewlett & Dr.S.K Singh, Affinity Health is a Juristic Rep of FSP 37213
1 Dingler Street, Rynfield, Benoni, 1501, Postnet Suite 124, Private Bag X101, Farrarmere, Benoni, 1518, Telephone: 0861 00 11 31,
Email: info@nbcrflihealth.co.za, www.nbcrflihealth.co.za

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Motor Accident clAiM ForM

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