Ajali
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Damaged Vehicle
Passenger Injured
Claim for Injured Passenger
Passenger Deceased
YES
NO
Passenger Name
Adult Passenger
YES
NO
Passenger Id Number
Passenger Date Of Birth
Passenger Mobile Number
Passenger Email Address
Passenger City Town
Paying Passenger
YES
NO
Mode Of Payment
Vehicle Registration Number
Vehicle Make
Police Station
Officer Name
Ob Number
Accident Cause
Type Of Injuries
Death Certificate Attachment
Is Psv
YES
NO
Is Sacco
YES
NO
Sacco Name
Is Vehicle Insured
YES
NO
Insurance Company
Insurance Policy Number
Insurance Scope Of Cover
Insurance Expiry Date
Driver Name
Driver Mobile Number
Driver Dl Number
Accident Date
Accident Time
Accident Town
Road Name
Road Surface
Weather
Visibility
Hospital Name
Hospital Town
Doctors Name
Days Spent In Hospital
Mortuary Name
Mortuary Town
Next Of Kin Name
Next Of Kin Adult
YES
NO
Next Of Kin Id Number
Next Of Kin Date Of Birth
Next Of Kin Mobile Number
Next Of Kin Email Address
Next Of Kin City Town
Next Of Kin Paying Passenger
YES
NO
Next Of Kin Mode Of Payment
Id Attachment
P3 Attachment
Please note you will be charged KES 100 application fee via M-pesa.
Submit Claim