First Name

Last Name

Date of Birth

ID No

Pin No

Phone No

Email Address

Start Date

End Date

P.O Box Kindly enter the correct address. Alphanumerics only

Postal Code / Zip Code eg 00100

Town eg Nairobi

+ Add Insured

Full Name

Relationship to Applicant

Phone

Email

Are you or any persons listed as the Insured suffering from any pre-existing respiratory conditions? Yes No
  Name and detail sof the illness/ disease or information and dates
 

Have you or any persons listed as the Insured travelled outside Kenya within the last 60 days, or are planning/intending to Travel outside Kenya during the period of cover? Yes No
  Name and detail sof the illness/ disease or information and dates
 

Upload Copy of ID/Passport for Policyholder

Upload Copy of KRA Pin for Policyholder

I hereby declare that the answers given above are to the best of my knowledge true and complete. I have declared all material facts which relate to this application. I authorise The Insurer to contact the doctor I have consulted or any Doctor of their choice if need be. I shall willingly submit myself for any medical examination if so required by The Insurer.