DEATH CLAIM
FILL FORMS IN BLOCK LETTERS
Date Reported
-
Month
-
Day
Year
Date
Policy Number
Policy Holder
First Name
Last Name
Email
example@example.com
Premium Payment Bank/Pay point
Staff ID.
Phone Number
Please enter a valid phone number.
Sum Assured: GHC
Email
example@example.com
Name of Claimant
Relations
Place Of Death
Age
Name of Deceased
Cause of Death
Date of Death
-
Month
-
Day
Year
Date
Kindly terminate premium deduction
Thick if you wish to
Pay me through
Bank
Cheque
Mobile Money
Name of Bank /Momo Account Name
Provide Mobile money account name if you choose Mobile money
Branch / Mobile Network
Bank Branch
Account Number /Momo Number
Enter Momo Number if you choose Mobile money
REQUIRED DOCUMENTS (Please Tick) :
Poilicy Document / Affidavit
Medical cause of death cert
Death Cert
Claimant/ Beneficiaries
Obituary
Others
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