MEDICAL INSURANCE
PROVIDER APPLICATION FORM
JUBILEE HEALTH INSURANCE LIMITED
DIRECTIONS:
Head Office: All questions must be filled in full block letters.
Jubilee Insurance Centre, Kilimanjaro Avenue,
P.O. Box 6694 - 00100 GPO, Nairobi, Kenya The dully filled application form and a comprehensive facility profile should be sent
Tel: +254 20 328 1000 to the email address medicalproviders@[Link].
Call Centre: +254 709 949 000
Email: talk2ushealth@[Link]
[Link]
Section 1:
Personal Information and Professional Documents
Attach the Certificate of Incorporation and Registration/Change of Name Certificate
Provider Type: Hospital: Health care facility: Specialist Clinic: Pharmacy: Optician: Other:
Provider Name:
Have you ever used another name in the past ? Yes No
If yes, kindly list all other names used and the period of use below
Period of use: Reason for Change:
Address and location
Attach list in case of multiple locations
Registered office:
Town: County: Address:
Postal code: Office telephone:
Mobile No: E-mail address:
Account details
Ensure the information provided is accurate since this will be the transaction details
Attach a copy of PIN, ID NO/Certificate of Incorporation and NHIF Certificate
Bank Name: Branch:
Branch No: Account Number: Swift Code:
Account Name: PIN NO:
ID NO: NHIF No:
Professional Documents
Attach copies of the Company Profile (details of the facility ownership and branches), licenses & certificates
Business Registration number: Date Issued:
Expiry Date:
Pharmacy and Poisons Board License No: Date Issued:
Expiry Date:
Private Practice License No: Date Issued:
Expiry Date:
Kenya Medical Practitioners and Dentists Board
Date Issued: Expiry Date:
Section 2:
Medical Practice Information
Primary Specialty Group
Attach copies of the evidence where applicable
Type of Practice: Solo Practice: Single Specialty Group: Multi-Specialty Group:
(Select only one)
What is your Primary area of specialty?
State other sub-specialty:
Services
Attach copies where applicable
Do you provide any of the following services ?
Laboratory: Yes No
If yes provide Accrediting/Certifying body:
Radiology Yes No
If yes provide Accrediting/Certifying body:
Pharmacy Yes No
If yes provide Accrediting/Certifying body:
Ambulance Yes No
If yes provide Accrediting/Certifying body:
Other Services:
Attach the services price list and CVs of the supervising staff for every section of your business
No of Staff: Are you accredited by the NHIF ? Yes No
If yes, provide your Rebates amounts:
Attach the NHIF Accreditation report
Working arrangements
Attach copies of the evidence where applicable
Do you have working arrangements with other providers ?
[Link]: Nature of Business:
State the Relationship:
2. Name: Nature of Business:
State the Relationship:
If you have more working arrangements kindly state in a separate page.
Admitting Rights
Attach copies of the evidence where applicable
Do you have Admission Rights with any Facilities Yes No
Name of the Facility Location of the Facility
If you have more Admission Rights kindly state in a separate page.
Section 3:
Insurance Cover
Professional Indemnity/Medical Malpractice Insurance Cover
Attach the cover details
Do you have PI cover for your institution staff/self ? Yes No
If yes, who is the insurer ?
Policy Effective Date: Policy Expiry Date:
Section 4:
Work History and References
Attach copies of the evidence where applicable
Are you a provider with any other Insurance firm ? Yes No
If yes, kindly state which Insurance firm you are currently working with:
1. Name of Insurer: Duration:
2. Name of Insurer: Duration:
If you have more working arrangements kindly state in a separate page
References
Provide two professional references who are not partners in your practice
1. Name:
Address: Postal Code: Town:
Country: Email Address: Telephone Numbers:
2. Name:
Address: Postal Code: Town:
Country: Email Address: Telephone Numbers:
Section 5:
Disclosure Clause
To be signed by two directors if it’s an entity & one signature for a practicing professional
Have you ever been charged or associated with any form of medical negligence? Yes No
Have you ever been associated with any illegal activities, fraud or any terrorism related activities? Yes No
If yes, please provide more details and attach any related documents
Name: Signature Date
Name: Signature Date
Name: Signature Date
Name: Signature Date
Section 6:
DECLARATION CLAUSE:
I/We the Undersigned Members
i. Hereby apply for myself/my entity to be registered on Jubilee Health Insurance provider panel.
ii. Warrant that the contents of this application and any other documents which may be required in support thereof are true,correct and
complete, should there be any change from the date of signing this application form and the date ofaccreditation by Jubilee Health
Insurance, notification of such change will be provided to Jubilee Health Insurance in writingwith full details of the changes.
iii. Understand that the statement and answers provided form the basis of the contracts Jubilee Health Insurance shall enter withme/us and
any breach of my warranty or non-disclosure of any information material to the assessment of this applicationshall render any contracts to
which this application relates null and void.
iv. Undertake to inform Jubilee Health Insurance within 30 days should the situation stated above change.
Signature & Stamp of Member/Institution: Date:
Name of Authorized Signatory: Date:
FOR OFFICIAL USE ONLY:
1. Provider Audited: Yes No
2. Provider Application: Accepted Declined
3. Vetting Officers:
Name: Designation Date
Name: Designation Date
Name: Designation Date
CONTACT US
JUBILEE HEALTH INSURANCE LIMITED
Head Office:
Head Office: Jubilee Insurance Centre, Kilimanjaro Avenue,
P.O. Box 6694 - 00100 GPO, Nairobi, Kenya
Tel: +254 20 328 1000
Call Centre: +254 709 949 000
Email: talk2usHealth@[Link]
[Link]
Jubilee Health Insurance Limited is regulated by Insurance Regulatory Authority.