• You can visit any of our branches countrywide • Speak to your agent or broker • Call us on 0711 065 100 / 020 2850 000.• Email: customerservice@uap-group.com

• Report all injuries to UAP Old Mutual Group offices• Complete the claim form and attach the relevant supporting documents e.g. receipts, medical reports etc.

Death or injury while the insured person is engaged in the following activities is excluded but can be covered for 50% of the cover limit at an additional premium of 25% of the basic premium of the limit chosen.

1. Racing2. Professional extreme sports3. Horse Riding4. Skating

DECLARATIONI warrant that the above statements made by me or on my behalf are true and complete to the best of my knowledge and belief and I agree that this proposal shall be the basis of the contract between me and the company. I also declare that no insurer has ever declined, refused to renew, terminated my insurance, increased my insurance premium or imposed special terms.I agree to accept a policy in the company’s usual form for this class of insurance

Signature:

Signed by: Date:

Agency:

LET’S TALK STUDENT PERSONAL ACCIDENT INSURANCE COVERThis is a comprehensive insurance package that provides cover against accidents that may happen to children of 3 years to 18 years. This cover is flexible enough and it has four options to chose from.

UAP Insurance Company LimitedP.O Box 43013-00100 Nairobi, Kenya

Tel. No: +254 711 065 100/+254 20 2850000. Email: customerservice@uap-group.com.

Website: www.uapoldmutual.com

How do I sign up for the cover?

How do I make a claim?

What are the exclusions of this cover?

(Please tick your mode of payment)

Cheque

Bank Transfer

Mobile money

Visa/Credit card

UAP Insurance Bank Details• Bank Name: Barclays Bank• Bank Code: 03• Account Number: 0451426400• Branch Name: Hurlingham Branch• Branch Code: 045• Account Name: UAP Insurance Company Ltd

For mobile money; kindly follow the below steps;• Go to M-PESA on your phone menu• Select Payment services• Select Pay Bill Option• Enter UAP Business Number- 505800• Enter the policy number as the account number• Enter the premium amount • Enter your M-PESA PIN• Confirm details and press OK

What are the available modes of payments?

How can I protect my child in case of an accident?

Schedule of Benefits

Medical Expenses

Permanent Total Disablement

Death

Artificial Appliances

Dental-Following Acc

Last Expense

Tuition during incapacitation

Options (Kes)

A

150,000

300,000

100,000

100,000

15,000

25,000

7,500/ weekly

B

100,000

200,000

100,000

75,000

15,000

25,000

5,000/Weekly

C

75,000

100,000

75,000

50,000

15,000

25,000

3500/Weekly

D

50,000

75,000

50,000

25,000

15,000

25,000

2500/Weekly

Premium Options

24 Hours Premium

Occupational Premium

A

900

650

B

600

400

C

450

300

D

350

250

Options

*Age restriction-Only above 3 years old

This cover caters for the following benefits and expenses;

• Medical Expenses -The cost of medical, surgical or other remedial attention treatment given or prescribed by a qualified medical practitioner.• Dental Expenses -The cost of dental treatment by a qualified dentist as a result of an accident.• Permanent total disablement- The cost of absolute disablement from engaging in the student’s ordinary occupation.• Cost of Artificial Appliances- The cost of appliances given or prescribed and registered member of the medical profession.• Tuition fees during incapacitation-Reimbursement of lost tuition fees paid to the school if the student is injured and unable to attend school for a maximum of eight 8 weeks.• EXCESS: Tuition Fees; excluding the first one week (the first 7 days )

What are the benefits of this cover?

What are the Limit options of this cover?

STU

DEN

TS P

ERSO

NA

L A

CCID

ENT

PRO

POSA

L FO

RM

Full

Nam

es

Posta

l Add

ress

Emai

l

Tel:

Land

line

C

ell

Bene

ficia

ry (C

hild

)Re

latio

nshi

p

PIN

ID N

o. (A

ttach

A C

opy

Perio

d of

Insu

ranc

e re

quire

d: A

nnua

l Dat

e - F

rom

To

Hav

e yo

u pr

evio

usly

hel

d a

Stud

ents

Pers

onal

Acc

iden

t Pol

icy?

Ye

s

No

If ye

s, n

ame

insu

rer

1. 2. 3. 4. 5. 6. 7. 8. A

re y

ou fr

ee fr

om p

hysic

al d

isabi

lity

or m

enta

l illn

ess t

o th

e be

st of

you

r kno

wle

dge?

Ye

s

N

o

If N

o, p

leas

e gi

ve d

etai

ls

9. G

ive

deta

ils o

f all

acci

dent

s whi

ch y

ou h

ave

susta

ined

dur

ing

the

last

five

(5) y

ears

Giv

e de

tails

of a

ll ac

cide

nts w

hich

you

hav

e su

stain

ed d

urin

g th

e la

st fiv

e

(5)y

ears

10. A

re y

ou e

ngag

ed in

any

of t

he e

xclu

ded

activ

ities

/oc

cupa

tions

men

tione

d be

low

?

Yes

No

(i). R

acin

g (ii

). Pr

ofes

siona

l ext

rem

e sp

orts

(iii).

Hor

se R

idin

g (iv

). Sk

atin

g

If ye

s, w

ould

you

like

an

exte

nsio

n of

cov

er (a

t 25%

of t

he b

asic

pre

miu

m) w

hile

eng

aged

in th

ese

activ

ities

?

Yes

No

11. C

over

sele

cted

A

B

C

D