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PLATINUM LIFE AND FUNERAL COVER
CLAIM FORM
Original Policy No.
(Please complete the form in BLOCK LETTERS and tick where applicable)
SECTION 1: POLICY HOLDER AND POLICY DETAILS
Surname:
Other Names:
Date of Birth:
Sex
Male:
Female:
National ID No.
Address: P.O. Box
Post Code:
Mobile No 1:
Mobile No 2:
Email:
Policy Number:
Underwriter:
Policy Commencement Date:
Town:
SECTION 2: DECEASED DETAILS
Surname:
Other Names:
Date of Birth:
Relationship to Policyholder
Date of death
Place of Death
National ID No.
Cause Of Death
SECTION 3: BENEFICIARY
Name:
Relationship:
Mobile No:
ID No.:
Preferred Method Of payment:
Bank Transfer
Account Name:
Bank Name:
Account Number:
Branch Name :
Branch Number :
Mobile Money
Network Provider:
Mobile Number:
Registered User:
Cheque
Payee:
DOCUMENTS REQUIRED:
Certified Copy Of Burial Permit
Copy of policy owners ID
Copy of deceased's ID.
Copy of beneficiary's ID.
DECLARATION
I declare that the statements and particulars on this form are true and that I have not misstated or withheld any material facts. I agree that this information
together with any other documents supplied are to the best of my knowledge true and correct and shall be relied upon to process this claim.
Claimant Name:
Claimant Signature:
Date:
Platinum Micro Insurance Brokers Limited
Hardy Office Park, Koitobos Road, Langata. Po Box 15670-00509, Langata, Nairobi.
Tel: 0709 900 000, Toll Free Number: 0800 722 100, E-mail: [email protected], website: www.platinum-mib.com