PRUDENTIAL LIFE INSURANCE DIGITAL FORM

DIGITAL ONLINE FORM
Client Full Name*

First NameLast Name
Phone Number*
E-mail
NATIONAL ID*
NATIONAL ID NUMBER*
Ghana Post Address*
PLEASE UPLOAD ID CARD HERE*

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Please verify that you are human*
Select Form*

AUTHORIZATION FOR PREMIUM DEDUCTION
Premium Payer Name*

First NameLast Name
Policy Number*
Deduction source*

Employer DeductionBank Deduction
Employer*
Suburb*
Town*
Region*
Employee Number*
Upload Authorization form for CAGD amendments

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SELECT BANK*
Branch*
Account Type*

SavingsCurrent
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*

Policy detailsPolicy StatementPolicy SchedulePayment DetailsOthers
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.
Date of Birth*

MonthDayYear
Date

SECTION 1

TO BE COMPLETED BY LIFE ASSURED
Name of Employer*
Address of Employer*
Employers Phone Number*
Please enter a valid phone number.
Occupation*
Date Last Worked*

MonthDayYear
Date

SECTION 1

TO BE COMPLETED BY LIFE ASSURED
Beginning Date of Disability*

MonthDayYear
Date
Describe Illness or Injury*
Have You returned to work*

YesNo
If Yes:*

Full DutyLight Duty
Return Date*

MonthDayYear
Date

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*

Clear

IDENTIFICATION OF BENEFICIARY
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Maiden names where applicable
Relationship to Claimant*

PARTICULARS OF BENECICIARY

CONTACT DETAILS (Telephone Numbers)
Home
Please enter a valid phone number.
Mobile*
Please enter a valid phone number.
Work
Please enter a valid phone number.
Postal Address

PARTICULARS OF BENEFICIARY

EMPLOYER DETAILS
Organization*
Occupation*
Telephone*
Please enter a valid phone number.
Address
Location

PARTICULARS OF BENEFICIARY

MEDICAL DETAILS
HOSPITAL NAME*
NAME OF DOCTOR*
PHONE NUMBER (DOCTOR)*
Please enter a valid phone number.
PHONE NUMBER (HOSPITAL)*
Please enter a valid phone number.

PARTICULARS OF BENEFICIARY

ADMISSION DETAILS
Date of Admission*

MonthDayYear
Date
Date of Discharge*

MonthDayYear
Date
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
Date

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.

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
Date
Maiden Name where applicable
Relationship to Claimant*

DECEASED PARTICULARS PRIOR TO DEATH

Contact Details (Telephone Numbers)
Home
Please enter a valid phone number.
Mobile*
Please enter a valid phone number.
Work
Please enter a valid phone number.
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.
Address
Location*

DECEASED PARTICULARS PRIOR TO DEATH

Religious Details
Religion
Denomination*

DECEASED PARTICULARS PRIOR TO DEATH

Death Description
Date and Time of Death*

MonthDayYear
Date
Hour MinutesAM/PM Option
Place of Death (Home, Hospital, Other)*
Cause of Death*

NaturalAccidental
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*

MortuaryFuneral Home
Body Tag Number
Name of Mortuary / Funeral Home*
Phone Number
Please enter a valid phone number.

DECEASED PARTICULARS PRIOR TO DEATH

Medical Details:
Hospital Name*
Name of Doctor*
Phone Number (Doctor)*
Please enter a valid phone number.
Phone Number (Hospital)*
Please enter a valid phone number.

DECEASED PARTICULARS PRIOR TO DEATH

Burial Information:
Has Deceased Been Burried*

YesNo
Name of Cemetery / Intended Cemetery*
Date / Intended Date of Burial*

MonthDayYear
Date
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.
Employer Details of Deceased Eldest Child*

PARTICULARS OF CLAIMANT
Policy Number*
Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
Home Contact
Please enter a valid phone number.
Mobile Contact*
Please enter a valid phone number.
Work Contact
Please enter a valid phone number.

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.

ACCOUNT DETAILS
PAYMENT OPTION

ELECTRONIC FUND TRANSFER (EFT)CHEQUEMOBILE MONEY (Can only pay up to GHC 5,000 )
SELECT BANK*
BANK BRANCH*
ACCOUNT NUMBER*
Account Name*
ACCOUNT TYPE*

SAVINGSCURRENT
Mobile Money Name*
Mobile Money Number *
MOBILE MONEY NETWORK*
Has your number being ported*

YesNo
(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*

Clear
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Should be Empty:

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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