Emma No Ento Wo Ansa

Maturity Claim Form

"*" indicates required fields

Applicant's Details

First Name*

First

Middle Name

Last name*

Email Address

Residential Address*

Street Address

Phone Number*

Policy Number

Staff Number

Request Details

Hidden

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.

Hidden

PREVIEW ENTRIES

Click "NEXT"to confirm your Entries Summary.>>>

Entries Summary Preview

This field is for validation purposes and should be left unchanged.