Family Funeral Nomination & Application form
Important Notes: This form consolidates all the various types of funeral insurance that Sanlam is on risk for. All references to insured will mean either employee or fund member.
This form must be completed by you, the insured, when:
The group risk insurance commences in terms of the policy.
There is a change in the information regarding your nomination of beneficiaries, as indicated in Section B. The Prudential Authority (PA), through the Insurance Act 18 of 2017 (the Act), also requires group policy benefits (e.g., unapproved benefits provided under a group insurance scheme) to be paid only to a “beneficiary”, as defined in the Act. Any benefit payment will therefore be strictly according to a valid beneficiary nomination form completed by the insured/employee; in the absence of a nomination form, the benefit will be paid to the deceased employee’s estate.
There is a change in the information regarding your family members, as indicated in Section C. Only immediate family members stated by you in Section C of this application will be covered and/or entitled to a benefit.
012 427 9910/6/7
087 942 3424/5
Monday to Friday, 08:00 - 15:00
Arc Building, 1134 Park Street, Hatfield,
Pretoria 0083, (Entrance in Grosvenor Street, opposite the Gautrain station) A. Particulars of insured Name (Required)
Gender (Required) Male Female Marital Status (Required) Single Married Living together Divorced Widow B. Beneficiary details (in the event of death of the Member)
I hereby nominate the following beneficiary to whom the funeral benefit must be paid in the case of my death:
Please Note: Only one beneficiary (18 years or older) may be nominated to receive the funeral benefit in the event of the member’s death. Name of Beneficiary (Required)
Relationship (Required) Spouse Son Daughter Stepson Stepdaughter Adopted Son Adopted Daughter Life Partner Father Mother Grandfather Grandmother Nephew Niece Cousin Uncle Aunt Friend Other Declaration by insured
I, hereby revoke all my previous nominations and now nominate the person mentioned above to receive the benefit payable in the event of my death in terms of the policy, or such portion thereof as is specified, subject to the provisions of the policy
Signature of Insured (Required) C. Application for Family funeral insurance
I hereby apply for the family funeral insurance, in terms of the policy, to be applicable to my immediate family members (i.e., the insured’s qualifying spouse and eligible child/ren)
Please Note: Unlimited number of children will be covered but only one qualifying spouse’s claim will be paid. If a person is in a cohabiting (living together) relationship, the partner (*) can only be nominated if neither one of the couples is married.
Dependants Relationship Spouse Son Daughter Stepson Stepdaughter Adopted son Adopted daughter Life Partner Father Mother Grandfather Grandmother Nephew Niece Cousin Uncle Aunt Friend Other D. Protection of personal information
Why Personal Information is required:
Sanlam Life Insurance Limited (“Sanlam”), a subsidiary of Sanlam Limited, will process and protect your personal information as required by relevant laws and the Constitution of the Republic of South Africa (“RSA”).
The personal information requested in this form, which may include special personal information is being collected and will be processed for the following purposes:
underwriting and providing accurate and effective insurance cover and related value-added services;
market research and statistical analysis;
verification of the personal information provided;
to comply with all legal and regulatory requirements, including applicable codes of conduct;
to protect Sanlam Life’s interests; and
any purposes related to the above.
Failure to provide the mandatory information will prejudice your insurance cover.
Changing and correcting Personal Information: You have the right to:
Request a copy of your personal information as processed by Sanlam;
Ask for an update and/or correction of your personal information;
Lodge a complaint with the Information Regulator.
Sanlam may charge an administrative fee subject to prior notice of any such cost before executing the request for a copy of your personal information.
Other parties that may receive the Personal Information:
Sanlam may share your personal information within Sanlam Limited and/or with other service providers where required for any of the purposes listed above, or with third parties where Sanlam is lawfully required to do so.
Sanlam may send your personal information to service providers outside the RSA for storage or further processing on Sanlam’s behalf
Sanlam will however not send your information to a country that does not have information protection legislation similar to that of the RSA, unless they have a binding agreement with the service provider which ensures that it effectively adheres to the principles for processing of personal information in accordance with the Protection of Personal Information Act, 2013.
For more information, please refer to the
Sanlam Group Privacy Notice E. Declaration of acceptance
Please read and understand the Summary of Benefits on the terms and conditions.
By virtue of my membership with the Tshwane Group Life Scheme, I am covered subject to its terms and conditions. I understand that the above information and supporting documents shall be the basis of the contract.
By signing this form, I declare:
The above information, whether in my own handwriting or not, is true and correct.
I understand that any false/incorrect information or misstatement in the application will invalidate any claim or benefit under the policy and I undertake to abide by the terms and conditions of the policy.
I understand that Sanlam has the right to defer a claim under this policy until all requirements, as specified by Sanlam, have been met.
Sanlam shall also not be liable for any claim until it has accepted this application and has received the first premium.
I confirm that I understand that I can claim for a benefit for the above-mentioned family members ONLY if they qualify in terms of the policy conditions and ONLY if I also pay the additional premium for this cover.
I declare that when I claim a benefit for a family member, I will prove my relationship to such a person.
I understand that I may not cancel my membership or participation in the Scheme for the duration of my employment with The City of Tshwane.
Signature of Insured (Required)