MADISON GENERAL INSURANCE KENYA LTD

CUSTOMER
CONSENT FORM

REQUIREMENTS
Must be an active registered Mpesa customer
Maximum amount payable through this method is Kes.100,000/=

Customer’s full name (as per the Id)_ _ID

NO (attach copy)

I hereby confirm my registration to Mpesa on cell phone number

(repeat cell phone number for verification) _

I hereby confirm that the information given above is correct.

Signature_ _ Date

DISCLAIMER:

Madison General Insurance Kenya Ltd will not be held liable for losses arising
from money being paid to the number provided above, should it be later found to
be a wrong number or money deducted by various credit facilities due to
customer having any arrears in his/her provided Mpesa number.

FOR OFFICIAL USE

Client cell phone number

Have you confirmed payee names? Yes No

Authorized by _Date Signature _