Credit Life Retrenchment Claim Form

Section A: Policy Holder Details

Section B: Nominated Credit Provider Details (If Applicable)

Credit Provider Bank Account Details (If Applicable)

Section C: Support 4 U Plan Details

Have you claimed on this policy before for any reason?
YesNo

If you answered "Yes"; Please supply dates and claim numbers:

Are you claiming under any other policy, with any other insurer, for unemployment or retrenchment, or will you do so in the near future?
YesNo

If you answered “YES“; please supply details of insurer, policy numbers and claim numbers

Section D: Work Details of Person Retrenched

What work do you normally do?
Please supply the following information of your last employer

Have you worked for the same employer for more than 12 Months?
YesNo

If you answered "NO"; please supply details of the previous employer

Retrenchment Claim

At the time of completing this form, did you have another job?
YesNo

Section E: Details Regarding Unemployment Insurance Fund (UIF) of Retrenched Person

Have you claimed on this policy before for any reason?
YesNo

If you answered “YES“; please supply details of UIF contact person

Section F: Supporting Documentation Required

Retrenchment Claim Form

Copy of Loan Contract (If Applicable)

Copy of Sanlam Developing Markets Policy Certificate

Client/Borrower Statement from your Loan Management System Copy of Policy (If Applicable)

Insurance Contract Cost Report (Proof of previous policies with Support 4 U)

Copy of Policyholder’s Identity Document

Retrenchment Letter from Employer on company letterhead

UI-19 Employer Declaration

POPI Act Disclosure and Permission:

(1) In line with the Protection of Personal Information Act no. 4 of 2013 I hereby give consent that all personal information supplied herewith may be used for the sole purpose related to the document intent herewith.

(2) I further consent that the data be used or exchanged with 3rd parties to validate information, fraud prevention, investigations, payments processing and product related marketing campaigns. I provide consent for Groups Are Us (PTY) Ltd to share my information with the external compliance officers for quality control and risk mitigating matters.

(3) Section 18 of the FAIS Act requires that records like client transactions, complaints, cancellations and financial records be kept for five (5) years. I understand that I can exercise my right to opt-out and avoid or stop any further use of my personal data within this disclosure after the record keeping requirement period is over.

(4) I acknowledge and understand that I can make contact with the Information Officer of Groups Are us (Pty) Ltd to lodge a complaint for any suspected abuse and/or
regulatory misconduct around my personal information processing or if personal information is being used for any reasons outside the intent of this document.

*For our privacy policy please refer or visit: www.groupsrus.co.za