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Assurance Company Limited!
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Samuel Antwi Yeboah
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Maturity Claim Form
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*
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Applicant's Details
First Name
*
First
Middle Name
Last name
*
Email Address
Residential Address
*
Street Address
Phone Number
*
Policy Number
Staff Number
Request Details
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Claim Type
Amount (GHS)
*
Mode of Payment
Your preferred payment mode is
*
Your preferred payment mode is
Open Cheque
Crossed Cheque
Bank Transfer
MTN Momo(Only)
Note that QLAC supports currently only MTN transfer for Mobile Money option.
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 Account
*
Account Name
*
Bank Name
*
Bank Branch
*
You have selected MTN Mobile Money Transfer option. Provide details below.
MTN Momo No.
*
Wallet Name
*
Terms and Agreements
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.
*
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 Documents
Please all required documentations below.
Policy documents
Upload your policy certificate
Accepted file types: pdf, doc, docx, Max. file size: 25 MB.
ID Card (Front view)
*
Accepted file types: jpg, jpeg, png, gif.
ID Card (Back view)
*
Accepted file types: jpg, jpeg, png, gif.
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