Medical Insurance Questionnaire

[Senior Cover(65+)]

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

Please note this form is for individuals of age range 65+.

If filling in on behalf of your parents or relatives, please fill it in with their details for accurate quotes:

Subject *

Email *

Name *

What is your date of birth? *

Is the cover for you only, or you and your spouse? *

If your spouse is included, share date of birth of spouse for accurate quote: Please note spouse also has to be 65+. If not, we will quote separately

Do you have NHIF? *

Yes and up to date

Yes but not up to date

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)

Optical

Dental

Other

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

Other

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

60,000 - 100,000

100,000 - 150,000

150,000

Other

Which hospitals do you frequent? *

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

Do you have any pre-existing conditions? *

What is your preferred mode of communication? *

Phone call

Whatsapp/Message

Any of the above

Other

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

How did you hear about us? *

@lerisqueafrica

thesoftlifespecialist

Agatha, The Wealth Tribe

Susan Wanjiku, Legacy Hub

Other

Submit

Nairobi • Kenya