Imana Insurance Agency

Car Insurance Application

With Imana Logo and Address

Client Name

Physical Address

Postal Address

ID/Passport Number

KRA Pin Number

Date of Birth

Telephone/Mobile Number

Email Address

Occupation

Vehicle Registration Number

Vehicle Value (For Comprehensive)

Vehicle Make

Vehicle Model

Vehicle Colour

Engine Capacity (CC)

Chassis Number

Engine Number

Vehicle Year of Manufacture

Type of Body - Saloon / Station Wagon

Vehicle Colour

Type of Cover

Any Additional Benefits? (e.g., Personal Accident)

Insurance Start Date

M-Pesa Paybill Number: 7596117
Account Number: Use Vehicle Registration Number

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