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Home
| Transaction Application Form
Transaction Application Form
Name of PolicyHolder
*
Email
Phone
*
Branch
*
Select Branch
Head Office
Asylum Down
Achimota
Teshie
Tema
West Hills
Ho
Koforidua
Takoradi
Cape Coast
Techiman
Sunyani
Kumasi
Harper Road Kumasi
Tamale
Bolga
Wa
Yendi
Agona Swedru
Hohoe
Tarkwa
Source of Premium deductions
*
Select Option
Institution
Bank
Institution:
*
Staff ID
*
Bank
*
Account Number
*
Policy Number
*
Transaction Type
*
Transaction Type
Withdrawal
Policy Refunds
Cashback
Maturity
Non Policy Refunds
Amount Required
*
Purpose
*
Reason for refund
*
Period
*
Indicate the Year
*
ID Type
*
NHIS
Passport
Voter’s ID
ECOWAS
Driver’s License
SSNIT
ID Number
*
Payment Mode
*
Payment Mode
MOMO
Bank Transfer
Registered Name
Registered No.
*
Account Name (as indicated at bank)
*
Name of Bank
*
Account Holding Branch
*
Account Number
*
Upload Bank Cheque Leaf
*
StarLife Assurance Company Limited does not accept responsibility for loss of funds resulting from providing incorrect details (name, telephone number, account number, bank and branch)
Signature of Client
*
By ticking, I hereby acknowledge that I have completely read and understand this form and all the information I have provided is correct.
Date
*
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