Prepaid Funeral Benefits - Claim Form
BENEFIT PAYMENT
The completion of this form is to enable the Deceased Members Legal Representative or Next of Kin or Authorised Represen-tative to apply for a first instalment of the deceased member's death benefit as determined by the Trustee, to assist in poy-ment of funeral costs. Where applicable, a death certificate or notice from Department of Justice, Birth certificate or Passport for the decease and applicant are required to be attached to this form. Other documents may be required upon request.
1. Member details - Cook Islands National Superannuation Fund
RMD Number
CINSF Member Number
Title
Mr
Mrs
Ms
Dr
Other
First name(s)
Surname
Residential Address
Home Phone
-
Country Code
Phone Number
Mobile Phone
-
Country Code
Phone Number
Email Address
example@example.com
Gender
Male
Female
Date of Birth (DD/MM/YY)
-
Day
-
Month
Year
Date
Final contribution date
-
Day
-
Month
Year
Date
Date of Death (DD/MM/YY)
-
Day
-
Month
Year
Date
BENEFIT AMOUNT
Value of prepaid Funeral Benefit being applied for
(Maximum of $5,000 or amount of sum insured, whichever is the lesser amount)
APPLICANT DETAILS
Applicant Name
Address
Telephone
-
Country Code
Phone Number
Email Address
example@example.com
Relationship to Member
Email: enquiry@superfund.gov.ck Phone: +682 25515 PO Box 3076, Avarua Rarotonga, Cook Islands WWW.CINSF.COM
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Prepaid Funeral Benefits - Claim Form
PAYMENT DETAILS
Pay to
Contact Details
Bank
Branch
Account Number
Branch Number
Swift code
Account Name
Applicant Signature
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Submit
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