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  • DEATH BENEFIT CLAIM FORM

  • DEATH BENEFIT | SPOUSAL BENEFIT

  • PLEASE READ THIS SECTION BEFORE COMPLETING THIS FORM.

  • Use this form to apply for a Death Benefit or Spousal Benefit
  • Important Information
    Before completing this form, please ensure that all required sections are completed and that the relevant supporting documents are attached. Incomplete or incorrect information may delay the assessment and processing of your claim. Please contact us if you need assistance completing this form or are unsure which supporting documents to include.

  • SECTION 1 TYPE OF BENEFIT – Please select one:

  • TYPE OF BENEFIT

  • SECTION 2 Deceased Member's Details

  • Title*
  • Date of birth (DD/MM/YYYY)*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Gender:*
  •  -
  •  -
  • Date of Death:*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Final payroll contribution date (DD/MM/YYYY)
     - -
    2 digit day, 2 digit month, 4 digit year

  • SECTION 4 Claimant Details

  • Title*
  • Date of birth (DD/MM/YYYY)*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Gender:*
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  •  -
  •  -

  • SECTION 5 Payment Details

  • SECTION 5 Claimant Declaration and Signature

  • Please read the statement carefully before signing.
  • By signing this form, I confirm that:
  • a. I declare that the information and supporting documents I have provided are true, complete and correct.
  • b. I understand that my entitlement to a death benefit and/or spousal pension will be assessed in accordance with the Cook Islands National Superannuation Fund Act, the Trust Deed and the Fund Rules.
  • c. I understand that the account balance remains subject to investment gains and losses until the claim has been approved.
  • d. I authorise CINSF to verify the information provided and obtain any additional information necessary to assess my claim.
  • e. I understand that providing false or misleading information may result in my claim being declined, recovery of any overpayment, or other action in accordance with the Fund Rules or applicable law.
  • Date (DD / MM / YYYY)
     - -
    2 digit day, 2 digit month, 4 digit year

  • SECTION 6 Required Information and Documents

  •  

    Death Benefit Claim Spousal Pension Claim
    a. Document for the deceased: a. Document for the deceased:
    • Death Certificate
    • Death Certificate
    • Passport (if available)
    • Passport (if available)
    • Birth certificate with a current photo
    • Birth certificate with a current photo

    b. The Claimant must provide: One (1) form of valid identification

    • Passport
    • Birth Certificate with current photo
    • Driver's License

    b. The Claimant must provide: One (1) form of valid identification

    • Passport
    • Birth Certificate with current photo
    • Driver's License
    •  Marriage Certificate (if claiming as spouse)
    • Letter of Administration (if applicable)
    • Grant of Probate and Will (if applicable)
    • Marriage Certificate

    c. Complete the following, if required:

    • CINSF Declaration of Family History
      Not required if a Letter of Administration or Grant of Probate has been provided.
    		  

    c. Provide the following:
    One (1) bank account confirmation:

    • Bank confirmation letter
    • Bank statement (local accounts only)
     

    d. Provide the following:
    One (1) bank account confirmation:

    • Bank confirmation letter
    • Bank statement (local accounts only)
    		  
    Note: Eligibility for any insured death benefit will be determined while the death claim is being assessed. CINSF will advise if additional documents are required  
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