Last Expense Claim Form - Birdview Microinsurance

Enter Code

Member Details

Privacy & Consent

Name of Member

Membership / Policy No.

Mobile No.

Amount Assured

Name of Claimant / Beneficiary

Relationship to Member

Claimant Address

Claimant Mobile No.

Amount Claimed

Corporate / Group Name (if applicable)

Bank Name

Branch

Account Name

Account No.

M-Pesa No.

M-Pesa Paybill (if applicable)

Reimbursement Amount

Medical Assessor Name

Medical Assessor Signature

Claims Manager Name

Claims Manager Signature

Burial Permit

Copy of Deceased’s ID

Copy of Claimant’s ID

Bank / M-Pesa Details