Death Claims Form

Step 1 of 2

Policy Number/ Card Reference Number

if you forgot your policy number please proceed to the next section

Policy Holder/ Premium Payer/ Beneficiary Name *

Please enter your full name

Claimant's National ID Number *

Please state your National ID Number in the format 00-000000N00

Claimant's Date of Birth *

Physical Address *

Please state your current physical address

Mobile Number (s) *

Please enter your mobile number

Email Address

Please state your email address (s)

Claim Type *

Please choose the applicable claim type

Are you receiving First Mutual Funeral Services

Name of claimant's employer and phone number *

Please state your employer's name, physical address and phone number

If No Please state the name of the name and contact of the Funeral Service Provider

Name

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