OldMutual Claim Request Form

Policy Holder Details

Full Name * :

Policy/Proposal Number *:

Address *:

Mobile Number As registered with us * :

ID Type * :

ID Number (Ghana) *:

Claim Type * :

Reason For Claim *:

Tin :

Email :

Proceed

Claim Payment Option

How do you want to receive the claim * :

Bank Name *:

Bank Branch *:

Account Number *:

Account Holder Name *:

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Disclaimer & Declaration

Old Mutual Life shall not be held liable for wrong account provided resulting in non-payment of claim

I, the undersigned, hereby declare that the information provided by me and required for me on this application is both correct and accurate, and the option selected herein is clear

Your Name *:

Sign your signature

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Policy Holder Details

Claim Payment Option

Disclaimer & Declaration

Sign your signature

Verifying ID Card

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