Medical Insurance Quote Form
The asterisk(*), part is a requirement.
Proposer Full name
*
individual, Business, Company
Date of birth
*
-
Day
-
Month
Year
As per the ID
Proposer ID Number
*
individual, Business, Company
Proposer KRA Pin
*
individual, Business, Company
Gender
*
Male
Female
Business, Company
Other
Policy start date
*
-
Day
-
Month
Year
Date
Policy end date
*
-
Day
-
Month
Year
Date
Category
*
Individual
Family
Senior(Above 65)
Corporate/Group
Other
Number of Members
*
M
M+1
M+2
M+3
M+4
M+5
M+6
M+7
corporate/group
Other
INPATIENT LIMIT
*
Please Select
100,000-senior
200,000-senior
250,000-both
300,000-both
500,000
750,000
1,000,000
1,500,000
2,000,000
3,000,000
5,000,000
6,000,000
10,000,000
12,000,000
OUTPATIENT LIMIT
*
Please Select
100,000-senior-
200,000-senior
250,000-All
Inp 300,000-All- Outp 50,000
Inp 500,000- Out 75,000
750,000- All
inp 1,000,000-outp 100,000
Inp 2,000,000-Outp 150,000
Inp 3,000,000- Outp 75,000
Inp 5,000,000- Outp 200,000
6,000,000- Outp 100,000
Inp 10,000,000- Outp 200,000
Inp 12,000,000- Outp 150,000
INPATIENT BENEFITS
*
Please Select
FAMILY SHARED
PER PERSON
OUTPATIENT BENEFITS
*
Please Select
FAMILY SHARED
PER PERSON
DENTAL,OPTICAL AND MATERNITY
IN BUILT IN SOME COMPANIES.
HOSPITAL TIER(LEVEL) FOR YOUR MEDICATION
*
Tier 3 & 4(Health centrer, small hospitals & sub county hospitals)-Annual lower premium.
Tier 5 & 6(County referral hospitals & National referral hospitals-Highest Level)-Annual higher premium.
SELECT THE MEDICAL COMPANY FOR QUOTATION.
*
HERITAGE INSURANCE COMPANY.
KENYAN ALLIANCE INSURANCE COMPANY.
OLD MUTUAL INSURANCE COMPANY
CIC GROUP INSURANCE COMPANY
MADISON INSURANCE COMPANY
BRITAM INSURANCE COMPANY
APA INSURANCE COMPANY
AAR INSURANCE COMPANY
JUBILEE INSURANCE COMPANY
Other
Applicants to be covered - Spouse or child
Family and Individual only
CORPORATE MEMBERS DATA
E-mail
example@example.com
Phone Number (Mobile) 1
*
Format: (+254) 000-000-000.
Phone Number (Mobile) 2
Format: (+254) 000-000-000.
ID Copy upload
Browse Files
Individual only
Cancel
of
KRA Pin Copy upload
Browse Files
Individual only
Cancel
of
Any other
Browse Files
Individual only
Cancel
of
Sign
*
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