Personal Accident Insurance Application

Client Name

Postal Address

Physical Address

Telephone / Mobile Number

Email Address

Occupation

🪪

Click or drag file here

JPG, PNG, PDF (Max 2MB)

📑

Click or drag file here

JPG, PNG, PDF (Max 2MB)

Name of Next of Kin

Mobile Number of Next of Kin

Relationship (Next of Kin)

Cover Limit

Have you suffered any accident previously?

Yes

If Yes, give details

Cover Duration

Insurance Start Date

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

This is only a summary for quick reference and not a substitute for policy documents.

Personal accident Registration Diskava . Beta . Kava