Sanlam Tower, Off Waiyaki Way, Westlands – Nairobi

P.O Box 44041 – 00400 Nairobi, Kenya

Tel: 0205138200 / 0202781305 / 0719035035
CLAIM REQUEST FORM Email: customerservice@sanlam.co.ke
Website: www.sanlam.com
PERSONAL DETAILS
Policyholder’s Name: __________________________________________________ Policy No: __________________
Claimant’s Name (If not Policyholder): _____________________________________ ID No: _____________________
Mobile No(s): ____________________________________Email: __________________________________________
Postal Address: _________________________Town: _________________________Post Code: _________________

REQUEST TYPE
Maturity Death Claim Cash Back Policy Loan
Part Maturity Critical Illness Cash Bonus
Refund (Loan/Premium) Personal Accident Others ……………………………….................
Surrender/Cancellation (Also tick reason below in case of surrender/cancellation)
Financial Misinformation Policy Performance Emigrating
Have Similar Product Poor Service Personal Schooling
Buy Other Sanlam Product Buy Competitor’s Product Others
Full reason for Surrender/Cancellation……….…………………………………………………………………………………
………………………………………………………………………………………………………………………………………
Personal Accident Maturity Part Maturity
Death & Loan & Cash back
DOCUMENTS (Tick as applicable)
Critical Illness Surrender Cash bonus
Refund
Notification Letter-----------------------------------------------------------------
Forwarding Letter-----------------------------------------------------------------
Police Abstract (RTA/Assault) ------------------------------------------------
ID (Deceased) – Certified Copy --------------------------
ID or Passport (Claimant) – Certified Copy--------------------------------------------------------------------------------------------------
Proof of Banking Details-------------------------------------------------------------------------------------------------------------------------
Police/ Postmortem Report (unnatural death) -------
Death Certificate – Certified Copy----------------------
Policy Document--------------------------------------------------------------------------------------------------------
Medical Report--------------------------------------------------------------------
Original Medical Expenses Receipt(s)--------------------------------------
Sick–off sheet(s)------------------------------------------------------------------
DDI/Salary Deduction Form & Payslip---------------------------------------------------------
Loan Application Form-----------------------------------------------------------------------------
Discharge Voucher / Benefit Claim Form-----------------------------------------------------------------------------

I authorize Sanlam Life Insurance Ltd to make payment of the benefit/claim requested above through (tick
applicable) BANK TRANSFER MOBILE MONEY. I confirm the details to be correct and fully absolve
Sanlam Life from my provision of incorrect payment details. Where method selected is mobile money, I confirm
that the number is registered in my name. Where the policy continues to be inforce, I authorise Sanlam Life to pay all future
benefits into the account/mobile number elected above, until otherwise advised by me in writing.
Bank Name: _________________________________________ Branch: _____________________________
Account Name: _________________________________________Account No.: _______________________
Or Phone No:
REPEAT NUMBER:
Where payment method selected is mobile money, I understand that use of this method for claim/benefit settlement shall be subject to the terms and
conditions of usage of mobile money services prescribed by the mobile service provider who issued the mobile number I have provided.
Note: If the payable amount is above Kshs. 150,000/=, payment shall be by bank transfer & bank details must be provided.

Client’s Name: __________________________________Signature: ___________________Date: _____________

OFFICIAL USE
Conservation comments: ___________________________________________________________________________
Received by (Name): ____________________________________Branch/Office: ______________________________
All forms received: YES NO
I confirm I have verified the documents, banking details signature of the client. Sign: _____________ Date: ___________
Processed By: _____________________________ Signature: ____________________ Date _____________________
Approved By: ______________________________ Signature: ____________________ Date _____________________

Regulated by the Insurance Regulatory Authority