Imana Insurance Agency

Travel Insurance Application

Client Name

Postal Address

Physical Address

KRA Pin Number

ID/Passport Number

Telephone / Mobile Number

Email Address

Date of Birth

Occupation

Country/City Travelling From

Country/City Travelling To

Date of Travel

Return Date

Purpose of Travel

Next of Kin Name

Next of Kin Telephone Number

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

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

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