Application to Dispense with Grant of Probate/Letters of ... - Aviva

Application to Dispense
with Grant of Probate/Letters
of Administration
Policy Number(s)
Life Insured
1. Did the deceased leave a Will
Yes
No
If so the original Will must be produced to
the Company
2. Did the deceased leave any assets
Yes
No
If so, please give details below (Assets should include value of private residence and any other property held by
deceased. If private residence or other property is held jointly, please indicate).
3. Are there any liabilities on the Estate
Yes
No
If so, please give details below (please indicate if funeral expenses are paid or not paid).
4. Is the deceased survived by a Widow/Widower
Yes
No
Full Name
5. Is the deceased survived by any children
Yes
No
Please give names below (Dates of Birth
required for children under 18).
Name
Date of Birth
/ /
/ /
/ /
/ /

6. If deceased was Single, was he/she survived by parents, brothers and sisters
Please give names below (Dates of Birth required for persons under 18) Please indicate any family members deceased.
Name
Date of Birth
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
I confirm that the answers to the above questions are correct and that I have not withheld any information in the event
of Aviva Life & Pensions Ireland Limited dispensing with Probate/Administration. If the Estate is €6,348.69 or under please
have Indemnity shown overleaf completed as indicated. The Company may also call for a Statutory Declaration. Certificate
of Discharge from Revenue Commissioners will be required in the case of No. 6 above.
Signature of Claimant
Date of Claimant / /

Form of Indemnity
In consideration of the payment of
€
in satisfaction and discharge of all claims under the policy(ies) indicated
overleaf I/we the undersigned
Name
Address
Name
Address
HEREBY UNDERTAKE AND AGREE at all times hereafter to INDEMNIFY Aviva LIFE & PENSIONS IRELAND LIMITED in respect
of all actions claims losses costs and expenses of whatsoever nature against or incurred by the said Company in relation to
the policy(ies) numbered overleaf or all or any of the proceeds thereof or in any other way concerning same.
Date this
day of 20
Legal Personal Representatives/Claimant Please Sign Here
X
X
X
X

Aviva Life & Pensions Ireland Limited. A private company limited by shares.
Registered in Ireland No. 252737 Registered Office One Park Place, Hatch Street, Dublin 2.
Member of the Irish Insurance Federation. Aviva Life & Pensions Ireland Limited is regulated by the Central Bank of Ireland.
Life & Pensions One Park Place, Hatch Street, Dublin 2. Phone (01) 898 7000 Fax (01) 898 7329
www.aviva.ie
Telephone calls may be recorded for quality assurance purposes.
5.19.02.13