Benefit Claim Request Form*

Benefit Claim Form

The application for the Death and Burial Benefit consists of this benefit claim form and any additional documentation to be submitted by you. Please fill out every space on the death claim form to avoid delays in our examination for the application for benefit. If a section does not apply or the information is not available, please write “NONE” in the space, so that we know you did not overlook that particular question. If an incomplete form is received, it may be returned for completion.
DISCLAIMER
- Submission of fraudulent document even in genuine cases may result in undue delay or outright repudiation of the claim.
- If after settlement of claim, Enterprise Life’s investigation prove that there was any fraudulent act in the processing of the claim, Enterprise Life reserves the right to prosecute the claimant and publish the act in any national dailies or newspaper.
Documents Required
- Death Certificate
- Medical cause of death
- Police report (in case of accidental death Burial documentation)
- Mortuary documentation
- Proof of age of deceased( Voters ID, National ID, NHIS card, baptismal cert, driver license,
  passport, pensioners id)
- Photo ID Card of claimant
NOTE: If you are having any challenges in accessing any of the above listed documents, Please do not hesitate to contact our Contact Centre: 0307 084444

Policy Number*
Details of Policyholder
Name of Policyholder*

First NameLast Name
Date of Birth of Policyholder*

DayMonthYear
Date
Mobile Number*
Work Telephone #
Home Telephone#
Email
Please provide your email address
Details of Claimant
Name of Claimant*

First NameLast Name
Date of Birth of Policyholder*

DayMonthYear
Date
Role of Claimant*
Mobile Number*
Physical Address*

Street Address

Street Address Line 2

City/TownState / Province

Postal / Zip Code
Ghana Post GPS Address (Claimant)*
Claimant’s Occupation
Employer/Organization’s Name
Employer/Organization’s Contact Number
Region*
Ashanti District*
Brong Ahafo District*
Eastern District*
Central District*
Greater Accra District*
Northern District*
North East District*
Savannah District*
Upper West District*
Upper East District*
Oti District*
Volta District*
Western District*
House Number*
Please provide Ghana Post Address
Notable Landmark to the House:*

Details of deceased
Name of deceased*

First NameLast Name
Date of birth deceased*

DayMonthYear
Date
Relationship to Policyholder*
Mobile Number
Physical Address*

Street Address

Street Address Line 2

City/TownState / Province

Postal / Zip Code
Ghana Post GPS Address (Deceased)*
Deceased Occupation:
Deceased Employer/Organization’s Name:
Deceased Employer/Organization’s Contact Number
Deceased Employers location:
Cause of Death*
Please provide the cause of death
Name of Hospital
Please search for the Hospital
Place of Death:*
Place of Accident
If accidental specify the following details
Name and Address of Police Station:
Accident summary
Date of Death:*

DayMonthYear
Date
Time of Death:*

:HourMinutesAM/PM Option
Body Deposited in a mortuary or funeral Home:*
Has the person been buried: (Yes/ No)*
Name of Mortuary*
Name of Cemetery:
Contact Details of Mortuary/Funeral Home
Date/ Intended Date of Burial:

DayMonthYear
Date
Name of Church/ Mosque that handled the burial Service
Name of Pastor/Imam
Phone Number of Pastor/Imam

Documents Required*

Death CertificateMedical cause of deathPolice reportMortuary documentationProof of age of deceasedPhoto ID Card of claimant
Please attach documents*

Browse Files
Upload required documents here Cancelof
Preferred option after processing death claim

Delete deceased life to reduce premiumMaintain premium to generate Extra Cash bonusReplace deceased life with another life

Other relationship to the deceased

	Spouse of deceased	Eldest child of deceased	Sibling working in a recognised institution
Name
Date of Birth
Phone Number
Physical Address
Employer Details

Payment Information
Payment Options*
Payment WebCs.
Payment WebCs
National ID Type*
National ID Number*
TIN Number
Taxpayer Identification Number (TIN)
Please upload National ID*

Browse Files
Please take a photo of your National ID Cancelof
Mobile Money Number*
Mobile Money Network*
Select Bank*
Account Holder Name*
Name of client on their bank account
Account Number*
Branch Name*
Branch Code*
DISCLAIMER

Enterprise Life shall not be held liable for non-payment as a result of wrong Mobile Number or Account Details given by client above.
DECLARATION OF A GENUINE CLAIM REQUEST*

I declare that the evidence of Death/Disability/Critical illness/Maternity complication/Female related illness/Hospitalisation/Still Birth that I present toEnterprise Life for the processing of my benefit are genuine and the event on which I make the benefit request is also genuine. I agree to have my policy cancelled with NO premium refunds should my claim turn out fraudulent.
Sign your Signature*

Clear
I further declare that the above statements and answers to the above questions are full and true, that I have withheld no material information and that I undertake to furnish any documentation which may be required by Enterprise Life. I expressly waive all provisions of law, customs or professional etiquette forbidding any physical or other person who attended or examined the deceased, or any institution in which the deceased received treatment, to disclose any knowledge or information which was thereby acquired and I authorize all such persons or agencies to furnish any information in their possession to Enterprise Life.
Profile Status
Select Bank New*
Account Holder Name New*
Name of client on their bank account
Account Number New*
Should be Empty:

Benefit Claim Form

Details of Policyholder

Details of Claimant

Details of deceased

Payment Information