Claim form

Bacarac Group Schemes | Lesedi House Funerals
Nedbank Building, 1st Floor, 7 Ryk Street, Welkom
086 053 7334 | 063 847 9692 | 082 867 7000
LesediHouseFunerals@Bacarac.co.za

Lesedi House Funeral Scheme - Claim Form

Lesedi House Funeral Scheme Claim Form

Policy Number

ID / Passport Number

Name & Surname

Phone No.

ID / Passport Number

Name & Surname

Phone No.

Relation to the Deceased Relation to the Deceased

Cellular Provider

ID / Passport Number

Name & Surname

Phone No.

Cause of Death

Date of Birth

Date of Death

Account Holder

Bank

Account Number

Account Type

Branch

Certified Death Certificate

Maximum file size: 67.11MB

DHA-BI1663(3 Pages)-Notice of Death

Maximum file size: 67.11MB

Certified ID copy Deceased

Maximum file size: 67.11MB

Certified ID copy Main Member

Maximum file size: 67.11MB

Certified ID copy Claimant

Maximum file size: 67.11MB

Burial Order (copy)

Maximum file size: 67.11MB

Bank Statement (First Page)

Maximum file size: 67.11MB

Signature of Claimant

Clear

Date

If you are human, leave this field blank.

BACARAC GROUP SCHEMES Authorised FSP | No. 37364 info@bacarac.co.za
082 867 7000

Administered by
4D Group Solutions
Authorised FSP | No. 14854

Underwritten by
King Price Life Insurance Ltd
Licensed Insurer | No 47235
Reg No. 1948/029011/06

Lesedi House Funeral Scheme - Claim Form

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