Users

Applicant's Details

First Name*

Middle Name

Last name*

Email Address

Residential Address*

Phone Number*

Policy Number

Staff Number

Request Details

Hidden

Claim Type

Amount (GHS)*

Mode of Payment

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*

Terms and Agreements

Signature*

Date of application*

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

Comments

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

Joyce Dogbe

Cyr Dogbe

adminQlife102022

Dogbe Dogbe

cyr dogbe

Francis Many

Cyr Dogbe

Leninsor Kakrabah-Quarshie

Isaac Ephraim

Sachael Zigarh