Imana Insurance Agency

Policy Information

Please provide your policy details

Claim Type *

Please select a claim type.

Policy Number/Car Registration Number *

Please provide a policy number.

Policy Period From *

Please provide the incident date.

Policy Period to *

Please provide the incident date.

Personal Information

Your contact details

First Name *

Please provide your first name.

Last Name *

Please provide your last name.

Email Address *

Please provide a valid email address.

Phone Number *

Please provide your phone number.

Physical Address *

City/Town *

Incident Details

Please describe what happened

Date of Incident *

Please provide the incident date.

Time of Incident

Location of Incident *

Please provide the incident location.

Description of Incident *

Please describe the incident.

Description of Damage/Loss *

Please describe the damage or loss.

Estimated Cost of Damage/Loss (KSh)

Additional Information

Please answer the following questions

Has the incident been reported to the police?

Yes

No

Were you issued with a police abstract?

Yes

No

Were there any fatalities?

Yes

No

Were there any witnesses?

Yes

No

Claim Documentation

We'll respond to your claim notification with an email on required documents.

Declaration

I declare that the information provided in this claim form is true and complete to the best of my knowledge. *

You must agree to the declaration to submit your claim.

Claim Form
Diskava . Beta . Kava

Insurance Claim Notification

Policy Information

Personal Information

Incident Details

Additional Information

Claim Documentation

Declaration

Claim Form Diskava . Beta . Kava

Insurance Claim Notification

Policy Information

Personal Information

Incident Details

Additional Information

Claim Documentation

Declaration

Claim Form
Diskava . Beta . Kava