Benefit Request Form

Benefit Request Form

Please provide the following details to request for benefit payment
Name of Client

First NameLast Name
Policy Number
Phone Number
Format: 0000000000.
Date of Birth

DayMonthYear
Date
Email
Please provide your email address
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
Source of Premium Payment
Select Premium Bank
Please search for your Bank
Select Bank
Please search for your Bank
Account Holder Name
Name of client on their bank account
Premium_webCs
Name of Employer
Staff Number
Momo Number
Mobile Money NumberFormat: 0000000000.