Nguzo ya Jamii

Personal Details

Enter your personal details

First Name

Last Name

Phone

Email

Date of birth

Gender

Male

Female

Marital Status

Single

Married

Address

Occupation

Insurance Plan

Describe your insurance plan

Insurance plan covers from

Contribution Paymeny Frequency

Monthly

Quarterly

Annually

Transfer

Other (Specify)

Mode of contribution payment

Cash

Standing rder

Check-Off

Direct Debit Instruction

Other (Specify)

Beneficiaries' Details

Enter the beneficiaries' details

Beneficiary 1

Beneficiary Name

Date of Birth

ID Number

Percentage (%)

Percentage: 0

Beneficiary 2

Beneficiary Name

Date of Birth

ID Number

Percentage (%)

Percentage: 0

Beneficiary 3

Beneficiary Name

Date of Birth

ID Number

Percentage (%)

Percentage: 0

Beneficiary 4

Beneficiary Name

Date of Birth

ID Number

Percentage (%)

Percentage: 0

Beneficiary 5

Beneficiary Name

Date of Birth

ID Number

Percentage (%)

Percentage: 0

Declaration by Member

Please read the below statement below and fill in your details.

I declare that the information provided above are to the best of my knowledge and belief true and complete and agree that this application shall form the basis of the contract between me and the Company. I understand further that the Trustees of the scheme have the final discretion to decide who should receive benefits but I request them to act according to my nomination. I also understand that for any of my nominated beneficiaries under the age of 18 at the time of my death, any benefits payable will be paid to my appointee/guardian named Below:

First Name

Last Name