TIP Family Protector – Tip Friendly Society

OVERVIEW

This form outlines documentation required to process a Family Protector claim. Please ensure all death-related documents are completed, stamped, and submitted promptly. Failure to provide any required item will delay claim processing.

Required Documents:

Family Protector Claim Form
Proof of Death (Physician’s Statement)
Proof of Death (Claimant Statement)
Marriage Registrar Document (where applicable)
Identification
ACH Authorization Form
Additional Documents Requested by TIP

MEMBER DETAILS

*Member Number

*TRN

Phone Number

*Full Name

*Email

*Alternate Phone Number

*Current Address

OVERVIEW

Please provide the details of your illness or disability below. These details help us process your claim accurately and ensure all required documents are collected. Your doctor will need to complete the Physician’s Statement, and in some cases your employer may also need to complete their statement.

1. This form consists of several sections. Please provide answers to all of the following information required in order to avoid delays with your claim. Please note that parts of this form are compulsory.
2. Please fill out this form completely and accurately; write N/A in areas that do not apply.
3. Only original receipts are accepted with Claim Form.
4. The issue of this form is not an admission of liability by TIP Friendly Society.
5. Only the surgeon’s fee is reimbursed under Sickness benefits.

PROOF OF DEATH CLAIMANT STATEMENT

*Name of Insured Person (if married woman, give maiden name also)

*Teacher Name

*Teacher Number

*School Name

*School Number

*Place Of Birth

Date Of Birth

*Residence at Death

Date Of Death

Occupation at Time of Death

Date last time worked full time at full pay

Cause of Death

When did Insured first complain or give other indications of last illness?

When did Insured first consult a physician for last illiness?

List all Physicians who attended the Insured during last illness and during three years prior thereto:

Dates:

Physician Name

Address

*Phone Number

Has Insured other Life Insurance? If so, in what Companies and for what amounts?

Company

Policy Number

Policy Date

Amount

In what capacity do you claim this Insurance?

Who has the certificate?

PROOF OF DEATH PHYSICIANS STATEMENT

This document must be completed directly by the attending physician, in the physician’s own handwriting, and includes the full medical certification of the cause of death, contributing conditions, dates of attendance, and any investigative procedures (inquest, autopsy, etc.) as required.

PROOF OF DEATH – Physician’s Statement Form Download

This form cannot be filled online. It must be downloaded and taken to the attending physician for completion. The physician is required to fill out all medical details by hand, including cause of death, relevant medical history, and dates of attendance. Ensure the doctor signs, dates, and stamps the form before you return to upload.

File Download

PROOF OF DEATH – Physician’s Statement Form Upload

Submit the fully completed and signed Physician’s Statement along with your other Proof of Death documents. Confirm that all handwritten sections, signatures, stamps, and dates are clear and legible to avoid processing delays. Upload only final, complete copies of the form.

*File Upload

X

ADDITIONAL DOCUMENTS REQUIRED

Birth Paper (Member and Deceased)

X

Death Certificate or Burial Order

X

Marriage Registrar (If married)

X

Police Record (If death is by accident)

X

ACH AUTHORIZATION - Please provide additional evidence of your banking details

*Name as it appears on your bank account:

I hereby authorize TIP Friendly Society to make direct deposit to my bank account as stated below:

*Name of Bank

*Amount:

*Branch

*Contact Number

*Account Number

*Account Type

Other Account Type

*Email Address

I acknowledge that if the information presented is erroneous, I will pay administrative fees of $1,000.00 to have the matter resolved and corrected.

Signature

Date

DECLARATIONS – COMPULSORY SECTION – REQUIRES COMPLETION

Privacy
TIP Friendly Society collects your personal information in order to calculate your loss and entitlements, determine our liability and handle claims. When handling your claim, we may have to disclose and obtain your personal and other information to and from third parties such as other insurers, reinsurers, loss adjusters, medical attendants, or other parties as required by law.

Authority
I authorise TIP Friendly Society to contact any Physician or medical attendant who has treated me or examined me or any person or
organisation that employs or has employed me or any other person or organisation who has or may have information regarding my
illness/injury for any information it may require to assist in the proof and settlement of my claim. A photocopy or faxed copy of this
authority can be acted upon as it was an original.

Declaration
I/we certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been
withheld.

I/we understand that this claim may be refused/denied if information is found to be untrue, inaccurate or concealed.

I/we acknowledge that I/we have read and understood the Privacy Section information and Authority referred to above and consent to the collection, storage and use and disclosure of my/our personal and sensitive information. I/we acknowledge that if I/we do not agree to the collection of this personal information, then TIP Friendly Society shall not be held liable for any settlement of claim

*Name of the Claimant

*Signature of the Claimant

Date

Signature of the Insured (If other than Claimant)

Date