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

ID/Passport

Policy Amount

Next of Kin

Full Name

Relationship to Applicant

Phone

Medical History

Are you or any persons listed as the Insured suffering from any pre-existing respiratory conditions? Yes No

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

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.

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COVID-19 Insurance Cover

Applicant Details

Address

Insured Persons

Next of Kin

Medical History

Declaration

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Applicant Details

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Medical History

Declaration

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