Signature. Date. 2.11 Part. 3 Deceased Details If NANTU Part 3. (a) the deceased was a member, fill in all sections under NOTE: If NANTU Part 3. (b) the deceased was not a member, do not fill in sections 3.11 3.14 under – Is NANTU Yes No 3.1 the deceased a member? Surname. 3.2 Full Name(s). 3.3 [Indicate 3.4 Title. Mr Mrs Miss Dr Proff. Other (x)] : with a cross [Indicate Marital Status 3.5 Single Married Divorced Widowed (x)] . with a Date Birth. 3.6 of Date 3.7 of ID Number. 3.8 Deceased 3.9 relationship to member. [Private] 3.10 Postal Address. Employee Code. 3.11 Date Last Contribution. 3.12 of Last Working Day 3.13 Name School/Institution. 3.14 of Part. 4 Banking Details Funeral Service Provider (FSP) of Account Name. 4.1 [Indicate Bank Name. 4.2 Bank Windhoek First National Bank NedBank Standard Bank NamPost (x)] with a cross Branch Name. Branch Code 4.3 Account Number. 4.4 Account Type. 4.5 Cheque Savings Other: : Postal Address. 4.6 Telephone No. 4.7
2.11 Signature. Date. Part. 3 Deceased Details NOTE: (a) If the deceased was a NANTU member, fill in all sections under Part 3. (b) If the deceased was not a NANTU member, do not fill in sections 3.11 – 3.14 under Part 3. 3.1 Is the deceased a NANTU member? Yes No 3.2 Surname. 3.3 Full Name(s). 3.4 Title. [Indicate with a cross (x)] Mr Mrs Miss Dr Proff. Other : 3.5 Marital Status . [Indicate with a (x)] Single Married Divorced Widowed 3.6 Date of Birth. 3.7 Date of 3.8 ID Number. 3.9 Deceased relationship to member. 3.10 Postal Address. [Private] 3.11 Employee Code. 3.12 Date of Last Contribution. 3.13 Last Working Day 3.14 Name of School/Institution. Part. 4 Banking Details of Funeral Service Provider (FSP) 4.1 Account Name. 4.2 Bank Name. [Indicate with a cross (x)] Bank Windhoek First National Bank NedBank Standard Bank NamPost 4.3 Branch Name. Branch Code 4.4 Account Number. 4.5 Account Type. Cheque Savings Other: : 4.6 Postal Address. 4.7 Telephone No.
CLAIM-FORM-A-Death.docx