Afya Imara Form

Afya Imara Medical Cover Application Form

PLEASE COMPLETE THIS FORM USING BLOCK LETTERS

It is important that you provide ALL the information requested to facilitate prompt processing of your application.

You must notify us of any change of contact details so we can ensure correspondence reaches you.

Please attach a copy of identification and PIN certificate of the policy holder and copy of Birth certificate for dependants below 18 years of age.

1. APPLICANT DETAILS - PARENT/GUARDIAN (Please note that the applicant will be the policyholder)

Details of existing and past health insurance policies

DEPENDANTS TO BE COVERED UNDER THE CONTRACT