NHIF claim for last expense and group life form

APPENDIX4

REPUBLIC OF KENYA

The Chief Executive Officer, National Hospital Insurance Fund, NAIROBI.

CLAIM FOR LAST EXPENSE AND GROUP LIFE – CIVIL SERVANTS AND DISCIPLINED SERVICES MEDICAL SCHEME

Guidelines

1. Part I of this form should be completed by the Head of Department at Ministry/State Department or County Head of Department of the deceased officer working under the National Government. For deceased officers under County Governments, Part I will be completed by Sub County/County Head of
2. Part II of this form should be filled by the Claimant/Next of Kin in the presence of the Head of Department of the deceased
3. Part III of this form should be completed by the Head of Human Resource Management in the Ministry/State Department/County Headquarters. The Head of Human Resource Management should certify that the claimant is the eligible
4. Original burial permit should be attached in support of a claim for Last
5. Original death certificate should be attached in support of a claim for Group
6. The original burial permit and death certificate will be returned to the Claimant on completion of the claim

PART I – STATEMENT OF PARTICULARS OF THE DECEASED

1. Full Name of Deceased Officer…………………………….………………………..…………………..…………….
2. Personal No………………………………………..National ID No……………………..……….…….……………….
3. Date of Birth…………………………………………Date of Death……….…………………………….………………

4. Designation……………………………………………………………………….…….Job Group……….……………

5. Ministry/State Department/County ………………………………………………..……………………….

6. Name of Head of Department…………………………………………………………………………………………….

Designation………………………………………………………………   P/No………………………………………………..

Ministry/State   Department/Department…………………………………………………………………………..

Signature………………………………………………………… Date…………………………………………………………..

PART II – STATEMENT OF PARTICULARS OF THE CLAIMANT/NEXT OF KIN (S)

1. Full Name     of     the     Claimant/Next     of     Kin(s)………………………………. ,

…………………………………………………………………………., ……………………………………………………………….., 2. National ID No……………………………..,…………………………………………,………………………………………..

Relationship to deceased Officer……………..……………..………………………………………………………….

3. Home County………………………………………….Sub County…………………………………………………………..

4. Location………………………………………………Sub-Location…………………………….………………………………

5. Contact Address……………………………………………..…………Phone No.………………………………………….

6. Bank Account Details:

Name of Bank……………………………………………………………………………………………………………

Branch…………………………………………………………………………………………………………………………….

Account   Name……………………………………………………………………………………………………………………….

Account   No……………………………………………………………………………………………………………………………

Signature………………………… (of duly nominated representative of next of kin (s)

Date…………………………………………………………

PART III – CERTIFICATION BY HEAD OF HUMAN RESOURCE MANAGEMENT IN THE MINISTRY/STATE DEPARTMENT/COUNTY HEADQUARTERS

I certify that Mr./Mrs./Ms…………………………………………………………………ID/ No……………. is the

eligible beneficiary and should be paid Last Expense/Group Life Claim in accordance with the provisions of the Civil Servants and Disciplined Services Medical Insurance Scheme.

Name of Head of Human Resource Management Division………………………………………………………

Designation…………………………………………………………………..P/No…………………………………….………….

Ministry/State   Department/County………..…………………………………………………………………………..…

Date……………………………………………………Signature……………………………………………………………………

PART IV – CASES TO BE ADMINISTERED BY PUBLIC TRUSTEES

All cases where the Principal Member dies without an updated list of beneficiaries, the last expense and Group Life benefits will be forwarded to the Public Trustee for administration as required by law.