Birdview Insurance
Last Expense Claim Form 2025
1
Member Details
2
Privacy & Consent
Step 1: Member & Claim Details
Name of Member
*
Name of Member *
Membership / Policy No.
*
Membership / Policy No. *
Mobile No.
*
Mobile No. *
Amount Assured
Amount Assured
Name of Claimant / Beneficiary
*
Name of Claimant / Beneficiary *
Relationship to Member
*
Relationship to Member *
Claimant Address
*
Claimant Address *
Claimant Mobile No.
*
Claimant Mobile No. *
Amount Claimed
Amount Claimed
Corporate / Group Name (if applicable)
Corporate / Group Name (if applicable)
Mode of Payment
Bank Name
Bank Name
Branch
Branch
Account Name
Account Name
Account No.
Account No.
M-Pesa No.
M-Pesa No.
M-Pesa Paybill (if applicable)
M-Pesa Paybill (if applicable)
Reimbursement Amount
Reimbursement Amount
Approved By (Official Use)
Medical Assessor Name
Medical Assessor Name
Medical Assessor Signature
Medical Assessor Signature
Claims Manager Name
Claims Manager Name
Claims Manager Signature
Claims Manager Signature
Required Supporting Documents
Burial Permit
Copy of Deceased’s ID
Copy of Claimant’s ID
Bank / M-Pesa Details
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