Partial Withdrawal

You have selected "Partial Withdrawal" option. Please fill in all required fields and submit your request.

First Name

Middle Name

Last Name

Address

Address Line 2

Phone/Mobile

Email

Policy Number

Staff Number

Mode of Payment

Mobile Money (MTN Momo Only)

Bank Transfer

Crossed Cheque

Open Cheque

Cheque Beneficiary Full Name

Cheque Claim Amount

Momo Number

Service Provider

Momo Account Holder Full name

Momo Claim Amount

Claim Amount

Account Number

Account Name

Branch

Bank

Upload Ghana Card ID (Front)

Choose File

Upload Ghana Card ID (Back)

Choose File

Signature

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