All Claims Form Contact QLAC ASSURANCE COMPANY LIMITED Claim Application FormCLAIM OPTIONSSelect From The Claim Types Maturity Claim Policy Loan Partial Withdrawal Surrender ClaimPreviousNextAPPLICANT'S DETAILSI, the undernamed hereby make an application for the above selected claimFirst NameMiddle NameLast NameApplicant's BranchE-mail of ApplicantApplicant's Phone/MobileAddress of Applicant Address Line 1Address Line 2PreviousNextCLAIM DETAILSConfirm Your Claim detailsPolicy NumberConfirm Claim TypePOLICY LOANMATURITYSURRENDERPARTIAL WITHDRAWALAmountGHSPreviousNextPAYMENT DETAILSFill in the required detailsMode of Payment- Select from options-Bank PaymentMobile Money PaymentBank Options Bank Transfer Cheque PaymentAccount NameBank NameAccoutn NumberBank Branch NameApplicant's Full NameMomo Account NameMomo Account NumberDisclaimer: 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 personPreviousNextUPLOAD YOUR IDUpload here your valid Identity Card and sign before submissionChoose Your ID Type- Select -Ghana CardPassportDriver’s LicenseID Card Front UploadChoose File ID card Back UploadChoose File I consent to have this website store my submitted information so they can respond to my inquirySignature Sign Here Date of Submission Previous Submit Application Form
