Claim Form - Imana Insurance Agency

1 Policy Information

Claim Type *

Policy / Car Registration Number *

Policy Period From *

Policy Period To *

2 Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

Physical Address *

City / Town *

3 Incident Details

Date of Incident *

Time of Incident *

Location of Incident *

Description of Incident *

Description of Damage / Loss *

Estimated Cost of Damage / Loss (KES) *

4 Additional Information

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

5 Documentation & Declaration

We'll respond to your claim notification by email with the list of documents required.

I declare that the information provided is true and complete to the best of my knowledge.

Claim Form
Diskava . Beta . Kava