PRUDENTIAL LIFE INSURANCE DIGITAL FORM

DIGITAL ONLINE FORM
Client Full Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
NATIONAL ID
NATIONAL ID NUMBER
Ghana Post Address
PLEASE UPLOAD ID CARD HERE

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Select Form

AUTHORIZATION FOR PREMIUM DEDUCTION
Premium Payer Name

First NameLast Name
Policy Number
Deduction source
Employer
Suburb
Town
Region
Employee Number
Upload Authorization form for CAGD amendments

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SELECT BANK
Branch
Account Type
Account Name
Account Number
Branch Code
Premium (GHC)
I authorize the above amount and any further updates to be deducted from my salary/Bank account for the payment of this insurance policy

ENQUIRY FORM
Policy Number
Postal Address
Enquiry Type

Others
Enquiry Details

DISABILITY CLAIM FORM

INSTRUCTIONS FOR COMPLETING THIS FORM
1. Life assured Completes SECTION 1 2. The physician who can verify disability must complete SECTION 2 3. BOTH PAGES of the complete signed claim form to be submitted 4. Medical report and or police report (in case of accident) must be attached

SECTION 1

TO BE COMPLETED BY LIFE ASSURED
Policy Number
Policy Number
Policy Schedule Number
Life Assured Name

First NameLast Name
Mailing Address

SECTION 1

TO BE COMPLETED BY LIFE ASSURED
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

SECTION 1

TO BE COMPLETED BY LIFE ASSURED
Name of Employer
Address of Employer
Employers Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
Date Last Worked

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

SECTION 1

TO BE COMPLETED BY LIFE ASSURED
Beginning Date of Disability

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Describe Illness or Injury
Have You returned to work
If Yes:
Return Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

SECTION 1

TO BE COMPLETED BY LIFE ASSURED
Comments
AUTHORIZATION TO RELEASE INFORMATION

By signing below, I authorize the release and disclosure of any information; including but not limited to: personal information, diagnosis(es), medical condition(s) and any reports that will aid the Prudential Life Insurance Ghana with its investigation of my claim with any party. I authorize any physician, hospital, medical or medically related facility where i have been treated, examined, admitted, or confined to release information concerning my medical history, mental or physical condition(s), or treatment which may be requested by Prudential Life Insurance Ghana or its duly authorized representative for the purpose of determining my eligibility for the benefits I have requested.
I HAVE READ AND UNDERSTOOD THE INFORMATION ON THIS FORM . I AFFIRM THE INFORMATION I PROVIDED HEREIN IS ACCURATE AND COMPLETE
LIFE ASSURED SIGNATURE

IDENTIFICATION OF BENEFICIARY
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Maiden names where applicable
Relationship to Claimant

PARTICULARS OF BENECICIARY

CONTACT DETAILS (Telephone Numbers)
Home
Please enter a valid phone number.Format: (000) 000-0000.
Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Postal Address

PARTICULARS OF BENEFICIARY

EMPLOYER DETAILS
Organization
Occupation
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Address
Location

PARTICULARS OF BENEFICIARY

MEDICAL DETAILS
HOSPITAL NAME
NAME OF DOCTOR
PHONE NUMBER (DOCTOR)
Please enter a valid phone number.Format: (000) 000-0000.
PHONE NUMBER (HOSPITAL)
Please enter a valid phone number.Format: (000) 000-0000.

PARTICULARS OF BENEFICIARY

ADMISSION DETAILS
Date of Admission

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Discharge

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total Number of Days
Reason for Admission
OPD / Hospital Card Number
PLEASE UPLOAD MEDICAL REPORT HERE

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PARTICULARS OF CLAIMANT
Policy Number
Name

First NameLast Name
Maiden Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

CONTACT DETAILS (Telephone Numbers)
Home
Mobile
Work
Postal Address
Email Address
example@example.com

EMPLOYER DETAILS

(name, location, contact number)
Name
Location
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.

ADDITIONAL INFORMATION
Additional Information
I further declare that the above statement and answers to the above questions are true and i have no relevant material withheld. I undertake to give any records which may be required by Prudential Life and clearly relinquish all provision of law, customer professional etiquette forbidden by a physician or other persons who attend to the deceased, or any institution the deceased received treatment, to disclose any knowledge or information which is by this means required by Prudential Life. I authorize all such persons and organizations to furnish any information in their possession to Prudential Life

IDENTIFICATION OF DECEASED
Name Of Deceased

First NameLast Name
Date of Birth of Deceased

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Maiden Name where applicable
Relationship to Claimant

DECEASED PARTICULARS PRIOR TO DEATH

Contact Details (Telephone Numbers)
Home
Please enter a valid phone number.Format: (000) 000-0000.
Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Work
Please enter a valid phone number.Format: (000) 000-0000.
Postal Address

DECEASED PARTICULARS PRIOR TO DEATH

Physical Address
Town
Suburb
House No
Notable Landmark

DECEASED PARTICULARS PRIOR TO DEATH

Employer Details
Organization
Occupation
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address
Location

DECEASED PARTICULARS PRIOR TO DEATH

Religious Details
Religion
Denomination

DECEASED PARTICULARS PRIOR TO DEATH

Death Description
Date and Time of Death

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Place of Death (Home, Hospital, Other)
Cause of Death
Exact Cause of Death
Summary of Accident
Place of Accident
Name and Address of Police Station

DECEASED PARTICULARS PRIOR TO DEATH

Details of Mortuary / Funeral Home:
Body Deposited at
Body Tag Number
Name of Mortuary / Funeral Home
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

DECEASED PARTICULARS PRIOR TO DEATH

Medical Details:
Hospital Name
Name of Doctor
Phone Number (Doctor)
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number (Hospital)
Please enter a valid phone number.Format: (000) 000-0000.

DECEASED PARTICULARS PRIOR TO DEATH

Burial Information:
Has Deceased Been Burried
Name of Cemetery / Intended Cemetery
Date / Intended Date of Burial

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name of Religious Body that Handled the Burial Service
Name of Deceased's Eldest Child
Contact Number of Deceased Eldest Child
Please enter a valid phone number.Format: (000) 000-0000.
Employer Details of Deceased Eldest Child

PARTICULARS OF CLAIMANT
Policy Number
Name

First NameLast Name
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Contact
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Contact
Please enter a valid phone number.Format: (000) 000-0000.
Work Contact
Please enter a valid phone number.Format: (000) 000-0000.

PARTICULARS OF CLAIMANT

Physical Address
Postal Address
Email
example@example.com
Town
Suburb
House Number

PARTICULARS OF CLAIMANT

Employer Details
Name
Location
Contact
Please enter a valid phone number.Format: (000) 000-0000.

ACCOUNT DETAILS
PAYMENT OPTION
SELECT BANK
BANK BRANCH
ACCOUNT NUMBER
Account Name
ACCOUNT TYPE
Mobile Money Name
Mobile Money Number
MOBILE MONEY NETWORK
Has your number being ported
(EFT to Stanbic Accounts will reflect one day after payment, payment to any other bank accounts will take 3 days) NOTE!! Prudential Life shall not be liable for payment of claim to wrong bank account and mobile money details provided by clients

COMPLETE AND SUBMIT
Signature
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DIGITAL ONLINE FORM

AUTHORIZATION FOR PREMIUM DEDUCTION

I authorize the above amount and any further updates to be deducted from my salary/Bank account for the payment of this insurance policy

ENQUIRY FORM

DISABILITY CLAIM FORM

1. Life assured Completes SECTION 1 2. The physician who can verify disability must complete SECTION 2 3. BOTH PAGES of the complete signed claim form to be submitted 4. Medical report and or police report (in case of accident) must be attached

SECTION 1

SECTION 1

SECTION 1

SECTION 1

SECTION 1

AUTHORIZATION TO RELEASE INFORMATION

I HAVE READ AND UNDERSTOOD THE INFORMATION ON THIS FORM . I AFFIRM THE INFORMATION I PROVIDED HEREIN IS ACCURATE AND COMPLETE

IDENTIFICATION OF BENEFICIARY

PARTICULARS OF BENECICIARY

PARTICULARS OF BENEFICIARY

PARTICULARS OF BENEFICIARY

PARTICULARS OF BENEFICIARY

PARTICULARS OF CLAIMANT

CONTACT DETAILS (Telephone Numbers)

EMPLOYER DETAILS

ADDITIONAL INFORMATION

DECLARATION OF SURRENDER / CANCELLATION

REINSTATEMENT OF POLICY

IDENTIFICATION OF DECEASED

DECEASED PARTICULARS PRIOR TO DEATH

DECEASED PARTICULARS PRIOR TO DEATH

DECEASED PARTICULARS PRIOR TO DEATH

DECEASED PARTICULARS PRIOR TO DEATH

DECEASED PARTICULARS PRIOR TO DEATH

DECEASED PARTICULARS PRIOR TO DEATH

DECEASED PARTICULARS PRIOR TO DEATH

DECEASED PARTICULARS PRIOR TO DEATH

PARTICULARS OF CLAIMANT

PARTICULARS OF CLAIMANT

PARTICULARS OF CLAIMANT

PARTICULARS OF CLAIMANT

ACCOUNT DETAILS

(EFT to Stanbic Accounts will reflect one day after payment, payment to any other bank accounts will take 3 days) NOTE!! Prudential Life shall not be liable for payment of claim to wrong bank account and mobile money details provided by clients

COMPLETE AND SUBMIT

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