Proposal/Application Form

Keke Personal Assurance & Safety Scheme (Keke PASS)
Product
Agent code
Amount Insured
Amount Payable
THE PROPOSER/APPLICANT
Title
Surname*
Other Names*
Gender Date of birth *
Address *
Occupation*
Phone Number*
Alternate Phone Number
Email Address*
Means of Identity [Voter's card, National ID, Rider's Permit, Driver's license]*
THE NEXT-OF-KIN DETAILS
Surname*
Other names
Relationship *
Address *
Gender Phone Number
Email Address*