Application – Gold Coast Insurance Agency

OCOA Boda Plan Application

Application Form

Insurance

Personal Details

First Name

Last Name

Date of Birth

ID Number

KRA Pin

Member of Bodaboda Association on Kenya

Next of Kin

Phone number of Next of Kin

Location Details

County

Sub-County

Ward

Home Address

Postal Address

Country

Contact Details

Email

Phone Number

I hereby declare that the answers given above are to the best of my knowledge true and complete.