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LIFE CLAIM FORM

Name of Claimant:

First Name

Middle Name

Date of Birth	Year (e.g. 1978)

E-mail Address

Phone Number:

Home Address:


Specify type of claim:	Insured	Uninsured

Nature of claim:	Maturity	Surrender

	Death

	Accident/Traffic Accident

Dissability Claim:

	* Please attach available documents

Name of Insurance Company:

Address of Insurance Company:

Details of Claim :

Sum Assured:

Policy No :

Date of Claim:

Date of Effect:

Attach any other relevant documents

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