Personal Accident Insurance Application

1 Client Information

Client Name *

Postal Address

Physical Address

Telephone / Mobile Number *

Email Address *

Occupation

2 Upload Documents

Click a card or drag your file onto it. JPG, PNG or PDF, max 2MB each.

Click or drag file here

JPG, PNG, PDF (Max 2MB)

Click or drag file here

JPG, PNG, PDF (Max 2MB)

3 Next of Kin Information

Name of Next of Kin *

Mobile Number *

Relationship *

4 Insurance Details

Cover Limit *

100K 200K 500K 1M 2M Other

Have you suffered any accident previously? *

Yes No

Cover Duration *

If Yes, give details

Insurance Start Date *

5 Payment & Notes

M-Pesa Paybill Number: 7596117
Account Number: Use your ID or KRA PIN Number

This is only a summary for quick reference and not a substitute for policy documents.

Personal Accident Registration Diskava . Beta . Kava