Health Save Plan

A Health Savings Account (HSA) is a unique, tax-advantaged account that can be used to pay for current or future healthcare (medical, dental or vision) expenses.

Get Quote

Fill in the form and we will get back to you shortly

1
Personal Details
2
Dependants' Provisions
3
Medical History
4
Insurance Company Selection

Personal Details

Enter your personal details

First Name

Last Name

Phone

Gender

Male

Female

Marital Status

Single

Married

Date of Birth

Address

Occupation

National ID/ Passport Number

N.H.I.F Number

Dependants' Details

Enter your insurance details

Dependant 1

First Name

Last Name

Date Picker

Relationship

Dependant 2

First Name

Last Name

Date Picker

Relationship

Dependant 3

First Name

Last Name

Date Picker

Relationship

Dependant 4

First Name

Last Name

Date Picker

Relationship

Dependant 5

First Name

Last Name

Date Picker

Relationship

Medical History

Enter your medical history

Have you or your dependants ever made a claim or received compensation for injuries?

Please select

Yes

If ‘Yes’ give details

Have you or your dependants ever suffered from

Gout?

Yes

Diabetes?

Yes

Paralysis of any kind?

Yes

A fit of any kind?

Yes

A rupture?

Yes

Varicose veins?

Yes

If ‘Yes’ to any of the above, give details of condition and treatment received

Are you or your dependants currently suffering from any illness, physical defect or infirmity?

Please select

Yes

If ‘Yes’ give details

Has any Insurance Company ever;

Cancelled your Policy?

Yes

Declined to insure you?

Yes

Declined to renew your Policy?

Yes

Imposed any special terms?

Yes

Declined any claim?

Yes

If the answer to any of the above is „YES‟, please give brief details below.

Insurance Company Selection

Below are some of the insurance companies in Kenya. Kindly select the insurance company whose policy you prefer.

Insurance Company Selection

Note: If your selected Insurance company does not offer this policy, we will notify you and guide you in your selection.

Thank you {First Name|text_3_52}

Form Submitted Successfully!

We will contact you as soon as possible.

Get App

+254 723 836 400

voolimobile@gmail.com

24th Floor,Britam Towers, Nairobi

Shopping Bag

Seamless Insurance