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Contact us

+254 114102667

Medical Insurance Questionnaire

(Individuals and Families)

This form is to guide us in preparing a suitable proposal based on your needs

This form is for individuals or families of up to age 64. If you are 65 and above please fill in this senior's form HERE

For individuals who want a stand alone cover for their children <18 fill in this Junior's Form HERE

Subject *

Email *

Name *

What is your date of birth? *

Is the cover for you, or you and your family? This includes spouse and children only. *

If your family is included share their dates of birth.

Do you have NHIF? *

Yes and up to date

Yes but not up to date

Do you have medical cover through work? *

Yes

Not Sure

Have you had personal medical cover before? *

Yes

Which one and overall experience:

What benefits are you looking into getting? *

Inpatient Only

Inpatient and Outpatient

Extra benefits you need: (you can only add dental and optical if you have outpatient cover)

Maternity

Optical

Dental

Other

Extra benefits you need: (you can only add dental and optical if you have outpatient cover).

Maternity

Other

Insurance premium budget range per annum: For premiums less than Ksh 50,000 please fill in budget form here *

50,000 - 80,000

80,000 - 100,000

100,000 +

Other

BUDGET

Other *

Which hospitals do you frequent? *

If you have a personal/family doctor which medical covers does he/she take?Your answer

Do you have any pre-existing conditions? *

How did you hear about us? *

What is your preferred mode of communication? *

Phone call

Whatsapp/Message

Any of the above

Other

Whatsapp /Message no.

Comments and/or questions that can help us better prepare for our meeting

Where did you hear about us: *

@lerisqueafrica

thesoftlifespecialist

Agatha, The Wealth Tribe

Susan Wanjiku, Legacy Hub

Other

Submit

Nairobi • Kenya

+254 114102667
cx@lerisqueafrica.com