Death Claim Form Contact Claim detailsDeceased personal detailsDeath detailsDeceased employment detailsPerson reporting detailsPayment methodFiles UploadSubmit Death ClaimYou have selected "Death Claim" option. Please fill in all required fields and submit your request.Policy NumberDate of Last PremiumPolicy NameClaim SumPreviousNextDeceased Full NameDate of DeathAge at Death (Years)PreviousNextCIRCUMSTANCE OF DEATH Did death occur through an accident? Yes NoIf ‘No’, how Did Death Occur? (Short description) Please Upload Police Report hereChoose File Proof of DeathProof of Death Was the deceased at Hospital? Yes NoName of the Hospital (if Yes)How long was the deceased at the hospital?(day, weeks, months)Duration at the HospitalPreviousNextDECEASED EMPLOYMENT STATUS Was The Deceased Employed? Yes NoWhen did he/she stop work?Date Company Was NotifiedPreviousNextPERSON REPORTING CLAIM’S DETAILS Full name(s)RelationshipPhone/MobileAddress Line 1Address Line 2PreviousNextMode of Payment Mobile Money (Personal Momo Number) Bank Transfer Cheque (Open Cheque / Crossed Cheque)Please indicate mode of payment*Phone/MobileBankBranchAccount NameAccount NumberPreviousNextUpload your IDChoose File Upload a valid Identication Card Upload Policy CertificateChoose File Upload your policy certificate PreviousNextSignature Sign Here Filing Date 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 Previous Submit Form
