Diaspora Funeral Cover
Policy Number:
*
Name of Life Assured:
*
Name of Claimant:
*
Address of Claimant:
*
Contact of Claimant:
*
Relationship to Life Assured:
*
--Select--
Spouse
Parent
Child
Sibling
Date & Time of Death:
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Cause of Death:
*
--Select--
Natural Death
Accident
For natural causes of death, provide details
Last physician, Name & Contact (For Natural Causes)
Attach Claimant ID
(5MBs Max)
:
*
Attach Police Report/Medical Report
(5MBs Max)
:
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Attach Death Certificate
(5MBs Max)
:
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Cente Diaspora Account Details
Account Name
*
Account Number
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Declaration
I hear by declare and confirm that I am the rightful claimant of this plan and that the details provided above are correct and true to the best of my knowledge. I have not withheld any relevant information and believe that the deceased is the same person as the life assured under the plan issued by Prudential Assurance Uganda Ltd
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