Health Insurance Registration

1 Client Information

Full Name *

Postal Address

Physical Address *

KRA PIN Number

ID / Passport Number *

Telephone / Mobile Number *

Email Address *

Date of Birth *

Occupation *

2 Spouse Information (Optional)

Spouse Name

Spouse Date of Birth

3 Children Information

Leave blank any child slots you don't need.

Child 1

Child 1 Name

Child 1 Date of Birth

Child 2

Child 2 Name

Child 2 Date of Birth

Child 3

Child 3 Name

Child 3 Date of Birth

Child 4

Child 4 Name

Child 4 Date of Birth

4 Insurance Benefits

5 Payment & Notes

Payment Information: After registration, you will receive payment instructions via email. Payments can be made via M-Pesa or bank transfer.

Important: This registration form is for application purposes only. The final policy terms and conditions will be provided by the insurer upon confirmation of cover.

Register for Health Insurance

Affordable Medical Coverage