Salama :

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Your Name
Email
Place Of Residence
Phone
Id Number
NHIF Number
Date Of Birth
Upload Your Passport Photo Here
Upload Your Id(showing Both Front and back

Dependents Details

include the details of your spouse and children (under 18 years) if any
Dependents Name
Dependent's date Of Birth
Relationship with 1st Dependent
Second Dependent Name
Second Dependent Date Of Birth
Relationship With 2nd Dependent
Third Dependent Name
ThirdDependent Date Of Birth
Relationship With 3rd Dependent

Next Of Kin


Your next of kin must be over 18yrs old
Name of next of kin
Relationship with next of kin
Parent/Child/Spouse/Friend etc

Health declaration by member


Are you aware of any condition in yourself or member of your family necessitating a medical maternity,surgical,dental or optical tratment at present?


I heareby declare that the statements in this form are true and complete.I further declare that i have not withheld any material information in regard to this application that ought to be disclosed to the company.I agree to abide by the rules governing the scheme.I consent that the company can seek information from any doctor,hospital or clinic i have consulted from.

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