CONTACT DETAILS UPDATE FORM

Principal Members name All premiums are Kshs.

Membership no.
Inpatient Plan
Outpatient Plan
Dental Plan
Optical Plan
Last Expense Plan
Personal Accident Plan
Other Plan
Total Premium Inclusive of Tax (Kshs)
Mode of Payment/ Payment Options Cash Cheque
(tick where appropriate) Mpesa Transfer
If the payment is paying more than one family please indicate

BANK DEPOSITS – KSHS. MOBILE MONEY - MPESA

BANK NAME : CBA BANK MPESA MENU SELECT; PAY BILL OPTION,
ACCOUNT NAME: RESOLUTION INSURANCE COMPANY LTD BUSINESS NUMBER: 503100 
ACCOUNT NUMBER: 7110120015  ACCOUNT NO. IS YOUR M/NO. E.G 123456 AS IT
BRANCH NAME: JUNCTION BRANCH APPEARS ON YOUR CARD.                            
BANK CODE: 07 BRANCH CODE: 017  KEY IN THE AMOUNT TO SEND,
SWIFT CODE:CBAFKEN  INPUT THE PIN NUMBER
 CONFIRM PAYMENT & SEND MONEY

Postal address: Post code: Town

Mobile phone no.: Alternative no.:
Email address: Next of Kin – name:
Next of Kin – Telephone no:
Beneficiary – Name: ______________________Beneficiary – Telephone no.:_______________

Any other instructions/comments: ___________________________________________

Signature: ________________ _____________________ Date_______
Preferred mode of communication;
Email or Postal address. (Tick where appropriate)
EMAIL POSTAL ADDRESS
Please note we can only renew members of your policy once we get a signed copy of this form.