OldMutual Claim Request Form

Enter policy number to verify

Policy/Proposal Number *:

Policy Holder Details

Full Name * :

Policy/Proposal Number *:

Address *:

Mobile Number As registered with us * :

Tin :

Email :

ID Type * :

ID Number (Ghana) *: Verify ID

Upload ID *:

(Optional) Comments if any:

Claim Type * :

Reason For Claim *:

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Claim Payment Option

How do you want to receive the claim * :

Bank Name *:

Bank Branch *:

Account Number *:

Account Holder Name *:

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Disclaimer & Declaration

Old Mutual Life shall not be held liable for wrong account provided resulting in non-payment of claim

I, the undersigned, hereby declare that the information provided by me and required for me on this application is both correct and accurate, and the option selected herein is clear

Your Name *:

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Enter policy number to verify

Policy Holder Details

Claim Payment Option

Disclaimer & Declaration

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