Micro health Insurance application - Imana Insurance Agency

Client Name

Postal Address

Physical Address

KRA Pin Number

ID/Passport Number

Telephone / Mobile Number

Email Address

Date of Birth

Occupation

Spouse Name

Spouse Date of Birth

Child 1 Name

Child 1 Date of Birth

Child 2 Name

Child 2 Date of Birth

Child 3 Name

Child 3 Date of Birth

Child 4 Name

Child 4 Date of Birth

Inpatient Benefit

Yes

No

Maternity Benefit

Yes

No

Outpatient Benefit

Yes

No

Optical/Dental Benefit

Yes

No

Last Expense Benefit

Yes

No

Insurance Start Date

Microhealth Insurance Registration
Diskava . Beta . Kava