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The cover you are applying forCarried over from your quotation where you came from one.

Insurer Cover type Plan Optional Cover limit selected Optional Annual premium As per quotation NCBA 4-instalment As per quotation

Group detailsThe organisation taking the cover.

Group / organisation name KRA PIN Registration number Nature of business Contact person Phone Email Physical / postal address Other group details Optional

Group documents PDF, JPG or PNG

Group KRA PIN certificate CR12 where applicable Group registration certificate

Members list CSV, Excel, PDF or ZIP Download the sample CSV One row per member and each dependant, repeating the employee number for a spouse and children — the same columns as the spreadsheet on the quotes page. Upload a CSV, an Excel sheet, a PDF or a ZIP of them.

How will you give the members?

One memberJust the member named below. Several membersAdd each one here, a row at a time. Upload the listA CSV, Excel, PDF or ZIP already filled in.

MembersEach family starts with its principal member, then anyone joining them.

Each family starts with its principal member, and anyone joining them — a spouse or a child — is added under that family, with their own relationship.

Principal memberThe person the cover belongs to.

Full names ID / passport number KRA PIN Date of birth Gender Height cm Weight kg BMI calculated Mobile number Email Occupation and employer Optional Physical / residential address Postal address Optional Applicant ID / passport copy PDF, JPG or PNG Applicant KRA PIN certificate PDF, JPG or PNG

Spouse and childrenOnly the dependants you want on the cover.

Spouse full names If included Spouse date of birth Spouse gender Spouse ID / passport Spouse KRA PIN Optional Spouse height cm Spouse weight kg Spouse BMI calculated Spouse ID / passport copy PDF, JPG or PNG

Children

Medical questions

Next of KinWho we contact in an emergency — this is not the beneficiary.

Full names Relationship Mobile number Email ID / passport number Physical / residential address

BeneficiaryWho receives the benefit, where the cover provides one.

Attach Other DocumentsAttach what you have now — the rest can follow.

Medical report or anything else Optional · PDF, JPG, PNG or Word · up to 8 MB each Choose FilesUp to 10 documents

How you will payOne of the two ways below.

Pay in FullPay the insurer directly and share your proof of payment — Ref: Client Name or Policy No. NCBA 4-Instalment OptionComplete the NCBA IPF form — 1st cheque payable to NCBA, 2nd–4th by standing order or post dated cheques.

Anything else we should know? Optional

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