Burial Cost Claim

UMCBF Registered Member Details

Policy Holder ID Number

Deceased's First Name

Deceased's Last Name

Deceased's other name (If Applicable)

Deceased's Date of Birth

MaleFemale

Deceased's Street Address

Deceased's Street Address Line 2

City

Postal/ Zip Code

Deceased's Date of Death

Place of Burial

NEXT OF KIN/ APPLICANT’S DETAILS

Name

Phone Number

Email

Relationship

Applicant/ Authorized Person's Signature

Date of Signature

Please upload Applicant Photo ID, Deceased Photo ID & UMCBF Member’s Death Certificate