Surrender Claim

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

First Name

Middle Name

Last Name

Address

Address Line 2

Phone/Mobile

Email

Claim Amount

Policy Number

Staff Number

Mode of Payment

Mobile Money (Only MTN Momo Number)

Bank Transfer

Crossed Cheque

Open Cheque

MTN Momo

Bank

Branch

Account Name

Account Number

Upload your ID

Choose File

Upload your Policy Certificate

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