Policy Loan "*" indicates required fields 123456 Applicant's DetailsFirst Name* First Middle Name (optional) First Last Name* First Email Address Residential Address* Street Address Your Phone Number*Staff No. Policy No. Requested DetailsHiddenClaim Type Amount (GHS)* Mode of PaymentYour preferred payment mode* Open Cheque Crossed Cheque Bank Transfer MTN Mobile Money You have selected Cheque Option. Please confirm beneficiary name below.Beneficiary's Name First You have selected Bank Transfer Option. Please provide details below.Bank Acc. No.Account Name* Bank Name* Bank Branch* You have selected MTN Mobile Money Transfer option. Provide details below.MTN Momo No.*Wallet Name* Terms and AgreementsTerms and Conditions*1. 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 2. Statements made shall be investigated. A person who makes a Claim based on any representation of existence of a statement of fact, knowing fully well that the representation if false, stands the risk of having the claim repudiated as well as being prosecuted for defrauding by false pretence to contrary section 131 of the Criminal Code Act. 29. I agree to the terms and conditions.Signature*Date of application* MM slash DD slash YYYY Upload Required DocumentsID Card (Front view)*Accepted file types: jpg, jpeg, png, gif.ID Card (Back view)*Accepted file types: jpg, jpeg, png, gif. Click Next to confirm your entries summary >>> Entries Preview NameThis field is for validation purposes and should be left unchanged.
