Claim Forms Maturity Claim Partial Withdrawal Policy Loan Surrender Death Claim Claim Forms Welcome to Quality Life Assurance Company Limited Claims formSelect from the tabs your claim. Fill in details and submit. A representative will contact soon afterward. Maturity Claim Start here Maturity Claim Form Personal DetailsContactClaim DetailsPayment detailsUpload filesSubmit Maturity ClaimYou have selected “Maturity” option. Please fill in all required fields and submit your request.First NameMiddle NameLast NamePreviousNextAddress Address Line 2Phone/MobileEmailPreviousNextClaim AmountPolicy NumberStaff NumberPreviousNextMode of Payment Mobile Money (Personal Momo Number) Bank Transfer Cheque (Open Cheque / Crossed Cheque)Phone/MobileBankBranchAccount NameAccount NumberPreviousNextUpload your IDChoose File Upload your Policy CertificateChoose File PreviousNextFiling Date QLAC will not be liable for payments made into wrong MoMo/Bank accounts provided by you. Kindly attach a valid ID and present same when collecting your cheque in person Previous Submit Form Partial Withdrawal Start here Partial Withdrawal Personal DetailsContactClaim DetailsPayment detailsUpload filesSubmit Partial WithdrawalYou have selected “Partial Withdrawal” option. Please fill in all required fields and submit your request.First NameMiddle NameLast NamePreviousNextAddress Address Line 2Phone/MobileEmailPreviousNextClaim AmountPolicy NumberStaff NumberPreviousNextMode of Payment Mobile Money (Personal Momo Number) Bank Transfer Cheque (Open Cheque / Crossed Cheque)Phone/MobileBankBranchAccount NameAccount NumberPreviousNextUpload your IDChoose File Upload your Policy CertificateChoose File PreviousNextFiling Date QLAC will not be liable for payments made into wrong MoMo/Bank accounts provided by you. Kindly attach a valid ID and present same when collecting your cheque in person Previous Submit Form Policy Loan Start here Policy Loan Claim Form Personal DetailsContactClaim DetailsPayment detailsUpload filesSubmit Policy Loan ClaimYou have selected “Policy Loan” option. Please fill in all required fields and submit your request.First NameMiddle NameLast NamePreviousNextAddress Address Line 2Phone/MobileEmailPreviousNextClaim AmountPolicy NumberStaff NumberPreviousNextMode of Payment Mobile Money (Personal Momo Number) Bank Transfer Cheque (Open Cheque / Crossed Cheque)Phone/MobileBankBranchAccount NameAccount NumberPreviousNextUpload your IDChoose File Upload your Policy CertificateChoose File PreviousNextFiling Date QLAC will not be liable for payments made into wrong MoMo/Bank accounts provided by you. Kindly attach a valid ID and present same when collecting your cheque in person Previous Submit Form Surrender Start here Surrender Claim Form Personal DetailsContactClaim DetailsPayment detailsUpload filesSubmit Surrender ClaimYou have selected “Surrender” option. Please fill in all required fields and submit your request.First NameMiddle NameLast NamePreviousNextAddress Address Line 2Phone/MobileEmailPreviousNextClaim AmountPolicy NumberStaff NumberPreviousNextMode of Payment Mobile Money (Personal Momo Number) Bank Transfer Cheque (Open Cheque / Crossed Cheque)Phone/MobileBankBranchAccount NameAccount NumberPreviousNextUpload your IDChoose File Upload your Policy CertificateChoose File PreviousNextFiling Date QLAC will not be liable for payments made into wrong MoMo/Bank accounts provided by you. Kindly attach a valid ID and present same when collecting your cheque in person Previous Submit Form Death Claim Start here Death Claim Form Claim detailsDeceased personal detailsDeath detailsDeceased employment detailsPerson reporting detailsPayment methodFiles UploadSubmit Death ClaimYou have selected “Death Claim” option. Please fill in all required fields and submit your request.Policy NumberDate of Last PremiumPolicy NameClaim SumPreviousNextDeceased Full NameDate of DeathAge at Death (Years)PreviousNextCIRCUMSTANCE OF DEATH Did death occur through an accident? Yes NoIf ‘No’, how Did Death Occur? (Short description) Please Upload Police Report hereChoose File Proof of DeathProof of Death Was the deceased at Hospital? Yes NoName of the Hospital (if Yes)How long was the deceased at the hospital?(day, weeks, months)Duration at the HospitalPreviousNextDECEASED EMPLOYMENT STATUS Was The Deceased Employed? Yes NoWhen did he/she stop work?Date Company Was NotifiedPreviousNextPERSON REPORTING CLAIM’S DETAILS Full name(s)RelationshipPhone/MobileAddress Line 1Address Line 2PreviousNextMode of Payment Mobile Money (Personal Momo Number) Bank Transfer Cheque (Open Cheque / Crossed Cheque)Please indicate mode of payment*Phone/MobileBankBranchAccount NameAccount NumberPreviousNextUpload your IDChoose File Upload a valid Identication Card Upload Policy CertificateChoose File Upload your policy certificate PreviousNextFiling Date QLAC will not be liable for payments made into wrong MoMo/Bank accounts provided by you. Kindly attach a valid ID and present same when collecting your cheque in person Previous Submit Form