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