Payment Request Form - Pioneer Assurance printable pdf download

Payment Request Form - Pioneer Assurance

PAYMENT REQUEST FORM

Policy number______________________________

I__________________________

National

Identity

Number_______________________of

Box_________________________________ in the republic of Kenya hereby request Pioneer Assurance

Company Kenya Limited of P O Box 20333-00200 Nairobi in the Republic aforesaid to pay my claim

amounting to Kshs ___________________ through Mpesa.

I confirm my registration to M- Pesa on cell phone number-----------------------------------------------------------

Repeat cell phone number for verification ______________________________

Signature of Policy Holder / Payee -------------------------------------------------------

Date--------------------------------------------------------------

DISCLAIMER

This service is available to you subject to the terms and conditions attached, which Terms and

Conditions you confirm to have read and understood and you are hereby bound to upon execution of

this Form.

For official use only: (to be completed by a Pioneer Assurance Company Kenya Ltd employee)

I have verified the following information (write down)

Client’s Cell phone number------------------------------------------------------

Name of Payee ------------------------------------------------------------------------

Verified by:

Name______________________________ Department_____________________________

Signature______________________________Date_________________________________

Payment Request Form - Pioneer Assurance