Claim Forms "*" indicates required fields 123 Claim Categories* Policy Loan Maturity Partial Withdrawal Surrender Death Claim Please indicate option from the list above and fill in all mandatory fields and submit your request. A customer representative will contact you as soon as possible. Policy Loan You selected "Policy Loan" option. Please fill in all required fields and submit your request.Partial Withdrawal You selected "Partial Withdrawal" option. Please fill in all required fields and submit your request.Maturity You selected "Maturity" option. Please fill in all required fields and submit your request.Surrender You selected "Surrender" option. Please fill in all required fields and submit your request.Your Full Name* Amount*Policy Number Staff Number Address* Branch Name* Telephone/Mobile*Mode of paymentPlease indicate mode of payment* Cheque (Open Cheque / Crossed Cheque) Bank Transfer MOBILE MONEY (personal MOMO number) Type of Cheque* Open Cheque Crossed Cheque Account Name* Acc. Number*Bank Name* Bank Branch* Wallet numberNote that QLAC currently pays through MTN Wallet onlyWallet Name* Signature*Upload your valid ID here* Drop files here or Select files Max. file size: 512 MB, Max. files: 2. Upload the front and back of your IDDate* Day Month Year Disclaimer:* 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 personSurrender You selected "Death Claim" option. Please fill in all required fields and submit your request.Death ClaimYou selected "Death Claim" option. Please fill in all required fields and submit your request. Deceased Full name(s)* Date of death* MM slash DD slash YYYY Age at death*Circumstance of Death Did death occur through an accident?* Yes No If ‘No’, how Did Death Occur? (Short description) Has the deceased at Hospital?* Yes No Name of the Hospital* How long was the deceased at the hospital?(day, weeks, months* Decease Employment StatusWas The Deceased Employed?* Yes No When did he/she stop work?* Day Month Year Date Company Was Notified* Day Month Year Date of Last Premium* Day Month Year Person Reporting Claim DetailsFull name(s)* Relationship Address* Email Address* Phone/Mobile*Claimant to Note* Statements made shall be investigated. A person who makes a Claim based on any representation of existence of a statement of fact, knowing fully well that the representation if false, stands the risk of having the claim repudiated as well as being prosecuted for defrauding by false pretence to contrary section 131 of the Criminal Code Act. 29.Required DocumentsUpload valid ID front viewAccepted file types: jpg, jpeg, png, gif.Upload valid ID back viewAccepted file types: jpg, jpeg, png, gif.Upload policy documentsMax. file size: 512 MB.Signature here*Application Date* Day Month Year Entries Preview NameThis field is for validation purposes and should be left unchanged.
