Death / Disability Claim Form - Prime Cure Health

IMPORTANT NOTE: Please email the completed form together with all supporting documentation to claims@kaelo.co.za. The death/disability claim will be processed within 14 days of receipt of all the requirements. Where no proof of bank details have been supplied, Prime Cure will not be held responsible for any payment made into an incorrect account.

I'm claiming for:

Death

Disability

Insured Details

Full Name

First Name

Last Name

ID Number

Date of Birth

Gender

Cellphone

Telephone

Email

Member Number

Medical Insurance Option

Claimants Details

Radio Buttons

Spouse

Legal Guardian

Personal Details:

Full Name

First Name

Last Name

ID Number

Date of birth

Gender

Cellphone

Telephone

Email

Member Number

Medical Insurance Option

Health Insurer

Beneficiary Bank Details:

The account holder must be the same as all the documents received.

Account Name

Bank

Account Number

Account Type

Branch Code

Signature

Clear

Proof of banking details for claimant

Maximum file size: 2MB

Password (if relevant)

If your uploaded file has a password please provide it for us here.

Supporting Documentation

Certified copy of death certificate

Maximum file size: 2MB

Certified copy of deceased ID

Maximum file size: 2MB

Certified copy of beneficiary ID

Maximum file size: 2MB

Affidavit/proof of relation to the deceased e.g. marriage certificate

Maximum file size: 2MB

Unabridged birth certificate for children below 18 years

Maximum file size: 2MB

In the case of unnatural causes, please include the Notice of Death/Stillbirth form from the Department of Home Affairs.

Maximum file size: 2MB

Certified Copy of Insured's ID

Maximum file size: 2MB

Certified Copy of Claimant's ID

Maximum file size: 2MB

Doctor’s Letter

Maximum file size: 2MB

A letter from the attending doctor confirming the insured’s disability, including diagnosis and description of the condition.

Employer’s Letter

Maximum file size: 2MB

A letter from the insured’s employer confirming: - The insured’s employment status - The insured’s inability to continue performing their job duties due to the disability