A New Dimension in Insurance

HEALTH DECLARATION
PLEASE ANSWER TO THE BEST OF YOUR KNOWLEDGE OR BELIEF
1. a) Name and address of your present doctor (If none, so state)
b) Date and reason last consulted (if within last 5 years)
c) What treatment was given or medication prescribed?

You may be required to complete a separate questionnaire or submit a medical report.

2. Do you or your dependant for insurance have any deformity, impairment or loss of hearing, vision (other than
defective vision which can be corrected by spectacles or contact lens) or limbs? Yes No
If the answer to any
3. (a) Ever been admitted into a hospital or had a surgical operation? Yes No
question is “Yes” identify
(b) Ever been advised to have a surgical operation which has not been performed? Yes No question number and
include diagnosis, dates,
4. To the best of your knowledge and belief, have you or your dependants for insurance ever had or ever been Yes No duration, degree of
told that you or your dependants have any disorder or disease of the following: recovery or results and
names and addresses of
(a) Skin, ears, nose, throat, eyes, e.g, otitis media, hearing problems, sinusitis, cataracts, glaucoma, Yes No
detached retina? all attending physicians
and medical facilities (if
(b) Stomach, intestines, liver, kidneys, gall-bladder, pancreas, bladder, prostate, urinary tract, e.g, hernia, Yes No the space is insufficient
cirrhosis, diabetes, protein in urine, piles? please append an
additional sheet)
(c) Lungs, bones, joints, cartilage, for example, asthma, bronchitis, pneumonia, tuberculosis, slipped disc, Yes No
fractures, arthritis, polio, muscular dystrophy?
(d) Heart, brain, mental or nervous disorder, e.g, low or high blood pressure, stroke, paralysis? Yes No
(e) Lymphatic system, for example, goiter, gout, thyroid? Yes No
(f) Cancer, tumour, cyst or growth of any kind? Yes No
(g) Female reproductive system, for example, cysts or fibroids, cysts of the breast, uterus or ovaries, cer- Yes No
vix, fallopian tubes ?
(h) Any other conditions not listed above? Yes No

5. During the past five years have you or your dependant for insurance consulted a physician for a general Yes No
examination or for any reason not previously noted on this form?

6. Are you currently taking any medication or any treatment regularly? Yes No
7. Are you currently suffering from any symptoms for which you have not yet consulted a doctor? Yes No
8. Are you or your dependants currently insured under any other medical, hospitalisation, accident or life Yes No
insurance?
If Yes, please give details: Insurer: ____________________________________________
9. Have you or your dependants for insurance ever had any medical, hospitalisation, accident or life insurance Yes No
application rejected or insurance cancelled, restricted, subject to special terms, or renewal declined?

MEMBERS DECLARATION
I confirm that All the above statements are true and complete to the best of my knowledge and belief and I uderstand that the Company, believing them to be such,
will rely on them for purposes of acceptance of this application. I consent to APA Insurance Limited seeking any information of my health records or health conditions
from any physician or health care provider or any organisation on my behalf and I hereby authorise the release of such information. A photocopy of this statement shall
be as effective and valid as the original.

This policy will only be effective after this application has been accepted by APA Insurance Limited and the premium paid in full. The insured accepts
APA’s condition that pre-existing and chronic conditions will not be covered for the first 12 months based on the information in the completed and signed
health declaration. Pre-existing conditions are not covered unless they have been declared by you in the Health Declaration section and accepted by
APA Insurance. The Insured hereby obliged on request to provide any further information that might be required.

All information supplied will be treated in strict confidence. All material facts including those relating to these questions must be disclosed. Failure to do so may
invalidate the policy. A material fact is any information that would be likely to influence the Insurer’s assessment and acceptance of this Proposal Form. If the Insured is
in any doubt as to whether a fact is material then it should be disclosed.

D D M M Y Y Y Y
Date SIGNATURE OF PRINCIPAL MEMBER

INTERMEDIARY DETAILS
Full name of Intermediary
Email Telephone No.
STAMP
Intermediary Declaration
I hereby declare that I have explained the benefits of this policy and that the applicant is fully aware of the membership terms and conditions of APA INSURANCE LIMITED.

Signature of Intermediary Date

D D M M Y Y Y Y

APA INSURANCE HEAD OFFICE

Apollo Centre, 07 Ring Road Parklands, Westlands, P.O Box 30065,00100 Nairobi. Tel: 254 (0) 20 286 2000. Fax: 254 (0) 20 286 2000
Email: info@apainsurance.org Website: www.apainsurance.org
BRANCH OFFICES
City Centre | Nakuru | Kisumu | Mombasa | Nyeri | Thika | Embu | Meru | Naivasha | Kisii | Eldoret | Machakos | Uganda
 A New Dimension in Insurance Attach 1 passport photo.

INDIVIDUAL HEALTH APPLICATION FORM

TO BE FILLED IN BLOCK LETTERS

POLICY HOLDER’S DETAILS

Male Female
Title:

Applicant’s Name
First Name Middle Name Surname

Date of Birth
D D M M Y Y Y Y KRA PIN No. (ATTACH COPY)

Occupation Mobile No.

ID/Passport No. (ATTACH COPY) Box No. Postal Code

Email Address City/Town

Physical Address

DEPENDANT’S DETAILS

DATE OF BIRTH GENDER RELATIONSHIP

NAME: (First Name, Middle Name, Surname)

D D M M Y Y Y Y MALE/FEMALE

Please attach a copy of Birth certificate/ notification (for children below 18 years)

NOMINEE/BENEFICIARY FOR LAST EXPENSE BENEFIT

Name Phone No.
ID/Passport No. Email

PLAN DETAILS

(TICK WHERE APPLICABLE)

JAMII PLUS COVER
PLAN Dazzle Brilliant Tosha Poa Classic

Inpatient 10,000,000 5,000,000 2,000,000 1,000,000 500,000

Optional Benefits
Outpatient 100,000 75,000 50,000

Maternity 120,000 100,000 50,000

Dental 30,000 20,000 10,000

Optical 30,000 20,000 10,000

AFYA NAFUU COVER

PLAN Affluent Executive Standard Select Mwananchi

Inpatient 1,000,000 750,000 500,000 300,000 100,000

Optional Benefits
Outpatient 100,000 75,000 50,000 40,000 30,000

Gross Premium Levies (0.45%) Stamp duty 40/= Total

APA INSURANCE HEAD OFFICE

Apollo Centre, 07 Ring Road Parklands, Westlands, P.O Box 30065,00100 Nairobi. Tel: 254 (0) 20 286 2000. Fax: 254 (0) 20 286 2000
Email: info@apainsurance.org Website: www.apainsurance.org
BRANCH OFFICES
City Centre | Nakuru | Kisumu | Mombasa | Nyeri | Thika | Embu | Meru | Naivasha | Kisii | Eldoret | Machakos | Uganda