Last Expense Insurance Questionnaire

This form is to help us accurately quote what is needed to support your family when it comes to the financial burden of losing a loved one.

Subject *

Full Name *

Email *

Date of birth *

Who are you looking to cover? *

Myself

Myself and My Spouse

Myself, My Spouse and My Children

My immediate family and members of extended family

Myself, My Spouse, My parents and My in-laws

Other

What are the ages of the family members you want to cover?

What level of cover are you looking to receive? *

200,000 KES

500,0000 KES

800,000 KES

1,000,000 KES

2,000,000 KES

3,000,000 KES

What is your preferred method of contact? *

Email

Phone Call

Text/Whatsapp

Other

Please share your contact if you chose phone call or text/whatsapp

Any questions/comments

How did you hear about us?

@thesoftlifespecialist

@lerisqueafrica

Other:

Other

Submit