Burial Benevolent Fund Claim Form

PART I – CONTRIBUTOR’S PARTICULARS

1. Name: Tel                         
2. TSC/No: BFF/No.                                         Society M/No.        
3. Current station and address:                                                                                                 
4. Date contributions commenced:                                                                                                

PART II – (i) PARTICULARS OF THE DECEASED

5. Name: Age:                             
6. Date of death: Place of death:                                    
7. Home Address: Town:                                           Code:     
8. Name of Assistant Chief                                                                                                      Address:                                                          Town:                                            Code:   

(ii) PARTCULARS OF THE CLAIMANT

9. Claimant’s Name: Tel No:                       
10. Address: Town:                                              Code:                
11. Relationship with Contributor:                                                                                               
12. Claimant’s Bank A/c: Bank :                                               Branch:     
13. Claimant’s Signature : Date:                         

PART III – SUPPORTING DOCUMENTS REQUIRED AND ATTACHED

14. Certified copy of Death Certificate/Permit for Burial                                                             
15. Birth Notification Form or Birth Certificate (for all claims on own child)                                   
16. Radio announcement or Newspaper caption or letter from Chief or Head of Institution
17. Any other document (specify)                                                                                                   

PART IV – CLAIM CONFIRMATION (Confirmation must be By Mwalimu Sacco Members)

18. 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

19. 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.

1. 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