User area – Qlife

First Name*

Middle Name

Last name*

Email Address

Residential Address*

Phone Number*

Policy Number

Staff Number

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Claim Type

Amount (GHS)*

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

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*

Signature*

Date of application*

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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Phone

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