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Applicant's Details

First Name*

Middle Name

Last name*

Email Address

Residential Address*

Phone Number*

Policy Number

Staff Number

Request Details

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Claim Type

Amount (GHS)*

Mode of Payment

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Open Cheque

Crossed Cheque

Bank Transfer

MTN Momo(Only)

Note that QLAC supports currently only MTN transfer for Mobile Money option.

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Beneficiary's Name

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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

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Policy documents

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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)*

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