Prepaid Funeral Benefits Claim Form

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.
Section 1 Decease Member details
RMD Number
CINSF Member Number
Title

Other
First name(s)
Surname
Residential Address
Date of Birth (DD/MM/YY)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Age
Mobile Phone

Country CodePhone Number
Date of Death (DD/MM/YY)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Final contribution date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Section 2 FUNERAL BENEFIT AMOUNT

If the balance is more than NZ$5,000A maximum of NZ$5,000 may be paid as the funeral benefit. Thispayment is the first payment from the deceased member's deathbenefit and is not the final settlement of the member's account.The applicant or beneficiary must submit a separate death benefitclaim to receive any remaining superannuation account balanceand any group life insurance benefit for which the deceasedmember was eligible.

If the balance is less than NZ$5,000 Only the amount available in the account will be paid as the funeralbenefit. If the full superannuation account balance has been paid asthe funeral benefit and the deceased member was not entitled to agroup life insurance benefit, no further payment will be due.

Value of prepaid Funeral Benefit being applied for
(Maximum of $5,000 or amount of sum insured, whichever is the lesser amount)
Section 3 APPLICANT DETAILS
Applicant Name
Relationship to Member
Physical Address
Telephone

Country CodePhone Number
Email Address
example@example.com
Email: enquiry@superfund.gov.ck Phone: +682 25515 PO Box 3076, Avarua Rarotonga, Cook Islands WWW.CINSF.COM

Prepaid Funeral Benefits - Claim Form
Section 4 PAYMENT DETAILS
Bank Name
Bank Number
Branch
Branch Number
Account Number
Account Name
Swift code (overseas accounts only)
Bank Address (overseas accounts only)
Applicant Signature

Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Section 5 Required Information and documents
CINSF cannot process your claim until all required information and supporting documents have been provided.

Tick each item to confirm it isattached.

A. COMPLETED CLAIM FORM

☐ Completed and signed Prepaid Funeral Benefit Claim Form

B. DOCUMENTS FOR THE DECEASED

☐ Death certificate or notice from the Department of Justice

☐ Birth certificate or passport of the deceased member

C. APPLICANT IDENTIFICATION

Provide one valid form of photo identification:

☐ Passport ☐ Birth certificate with a current photo ☐ Driverlicence

D. BANK ACCOUNT CONFIRMATION

Provide one document confirming the bank account stated inSection 4:

☐ Bank confirmation letter

☐ Recent bank statement — local accounts onl
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Prepaid Funeral Benefits Claim Form

BENEFIT PAYMENT

Section 1 Decease Member details

Section 2 FUNERAL BENEFIT AMOUNT

Section 3 APPLICANT DETAILS

Prepaid Funeral Benefits - Claim Form

Section 4 PAYMENT DETAILS

Section 5 Required Information and documents