Give the name and address of your personal doctor or medical facility where your medical records may be obtained:
I accept that I am curtailing my right of privacy, to facilitate the assessment of the risks, and the consideration of any benefits
under a policy related to this or any other application for insurance made by me, or in respect of me as life to be assured and
hence irrevocably authorise that:
NOTE: Information regarding your insurability will be treated confidentially. We may however, make required reports to the Association of Kenya Insurers Life Registry and may also release information to other insurance companies to whom you apply for insurance or to whom a benefit claim may be reported.