Death Claim
The issue of this form is NOT an admission of liability on the part of the Company. Please answer all questions fully and return form without delay to
ALLIANZ NIGERIA INSURANCE PLC
1
Policy Details
Policy Number
2
DETAILS OF LIFE ASSURED
FULLNAME
DATE OF DEATH
Place of Death
Place of Burial
Residential Address
Work Place Address
Name of Next of Kin/Beneficiary
Relationship
Next of Kin/Beneficiary Phone Number
E-Mail:
*
3
DETAILS OF PHYSICIAN WHO ATTENDED TO THE LIFE ASSURED
NAME
HOSPITAL NAME
HOSPITAL ADDRESS
HOSPITAL PHONE NUMBER
Doctors Registration Number
Doctors Signature
Submit
Send Filled Content
Receivers' Email