Name *

ID No. * Institution *

Phone.* Email* KRA*

Select Attachment/Internship period (a rough estimate is also fine).
  3 months (KES 400/=)   For Sum Insured of (KES 50,000/=)
  6 months (KES 600/=)   For Sum Insured of (KES 50,000/=)
  12 months (KES 1,000/=)   For Sum Insured of (KES 50,000/=)

Start Date* Attachement *

Payment Details