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You are here: Claim Application Form

CLAIM APPLICATION FORM

Tel: (+233)0302-678130,672356,663389,678126,66696 / Fax:(0302)671072, 671072 / Email:claims@siclife.com.gh: www.siclife.com.gh

Name of Policyholder / Applicant

Policy No.

Mobile No.

Deduction Source

Staff ID/ Payroll No

Account No

Others (state)

ID Type

ID Number

Address of Applicant

Tick type of CLAIM applied for Partial Withdrawal Paid-Up Maturity

Claim amount required

SURRENDER

Reason for Surrender

Modes of payment Bank Chit-Token Mobile-Money

Momo Number

Momo Name

Network

Name of Bank:

Branch

Account Name

Account number:

DATE:

Time

ATTACH other documents

Office Use only

CUSTOMER SERVICE USE: claim eligibility checked Yes No

Attended by

Sign

Branch

Policy Status

Last premium Date

for the Month of

Name/Sign

date

For anomalies in premium forward to Premium Administration for corrections: Remarks

Cash value

claim amount

signature

APPROVAL

Approved by

date

I have receive cash/cheque no.

I AGREE that the entries provided for each field above is accurate and thereby consent to the processing of personal data necessary to achieve the required objective. Agree Do Not Agree