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.
As part of our ongoing efforts to transform your customer service experience, we are pleased to announce the launch of LifeConnect.

All service requests will be exclusively through LifeConnect.

Please see below;
https://lifeconnect.enterprisegroup.net.gh

LifeConnect offers several enhanced, customer-focused features, including
• Real-time request tracking,
• A comprehensive request history
• Improved KYC and payment verification

You may also reach us on phone (0307084444) for support.

Thank you
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
2 digit day, 2 digit month, 4 digit yearDate
Mobile Number
Format: 0000000000.
Work Telephone #
Format: 0000000000.
Home Telephone#
Format: 0000000000.
Email
Please provide your email address
Details of Claimant
Name of Claimant

First NameLast Name
Date of Birth of Policyholder

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Role of Claimant
Mobile Number
Format: 0000000000.
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
2 digit day, 2 digit month, 4 digit yearDate
Relationship to Policyholder
Mobile Number
Format: 0000000000.
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
2 digit day, 2 digit month, 4 digit yearDate
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
2 digit day, 2 digit month, 4 digit yearDate
Name of Church/ Mosque that handled the burial Service
Name of Pastor/Imam
Phone Number of Pastor/Imam

Documents Required
Please attach documents

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

Other relationship to the deceased

Rows	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
Format: 0000000000.
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
Sign your Signature

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