Burial Benevolent Fund Claim Form
PART I – CONTRIBUTOR’S PARTICULARS
- Name: Tel
- TSC/No: BFF/No. Society M/No.
- Current station and address:
- Date contributions commenced:
PART II – (i) PARTICULARS OF THE DECEASED
- Name: Age:
- Date of death: Place of death:
- Home Address: Town: Code:
- Name of Assistant Chief Address: Town: Code:
(ii) PARTCULARS OF THE CLAIMANT
- Claimant’s Name: Tel No:
- Address: Town: Code:
- Relationship with Contributor:
- Claimant’s Bank A/c: Bank : Branch:
- Claimant’s Signature : Date:
PART III – SUPPORTING DOCUMENTS REQUIRED AND ATTACHED
- Certified copy of Death Certificate/Permit for Burial
- Birth Notification Form or Birth Certificate (for all claims on own child)
- Radio announcement or Newspaper caption or letter from Chief or Head of Institution
- Any other document (specify)
PART IV – CLAIM CONFIRMATION (Confirmation must be By Mwalimu Sacco Members)
- I confirm that the claimant is known to me and that the death occurred as described in Part II (above) and I therefore recommend the payment
NAME: NAME:
Tsc. : No MNO: Tsc. No: MNO: Signature : Signature: Tel. No: Tel. No:
PART V – BRANCH ENDORSEMENT
- I confirm that the claimant is a member of the branch and that death occured as described
Branch: Delegate name: Sign: Date:
OFFICIAL USE:
Activated by: Date: Approved by: Date: Processed by: Date:
Mwalimu National
Mwalimu Towers, Hill Lane off Mara Road – Upper Hill.
- O. Box 62641 – 00200 Nairobi, Kenya. Tel: (0)20 295 6000 /+254 709 898 000 SMS only: +254 721 270 944
E-Mail: [email protected] Website: www.mwalimunational.coop