COVID-19 Insurance Cover Applicant Details First Name Last Name Date of Birth ID No Pin No Phone No Email Address Start Date End Date Address P.O Box Kindly enter the correct address. Alphanumerics only Postal Code / Zip Code eg 00100 Town eg Nairobi Insured Persons Full Name Occupation Date of Birth Gender --- Male Female Other ID/Passport Policy Amount 100,000 200,000 300,000 400,000 500,000 + Add Insured Next of Kin Full Name Relationship to Applicant Phone Email Medical History 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 Declaration 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. Important notice We are unable to process your application at this time. Please contact GA Insurance using the details below for more information:- Call Centre Number: +254709626400 Call Centre Email: firstname.lastname@example.org Submit We've detected that you are not logged in. Please log in or sigunp before proceeding. Don't worry - you won't have to fill in the form again. Email Password Username Email A password will be e-mailed to you.