Imana Insurance Agency

Personal Accident Insurance Application

Client Name

Postal Address

Physical Address

KRA PIN Number

ID/Passport Number

Telephone / Mobile Number

Email Address

Date of Birth

Occupation

Name of Next of Kin

Mobile Number of Next of Kin

Relationship (Next of Kin)

Cover Limit

Have you suffered any accident previously?

Yes

If Yes, give details of the accident

Are you looking for 3, 6, or 12 months cover?

Insurance Start Date

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

This is only a summary for quick reference of your insurance and not a substitute for the policy documents.