GROUP MEMBERSHIP REGISTRATION FORM

REQUIREMENTS

1. Must pay a registration fee of Kshs. 3,000/-

2. Must present a photocopy of group certificate that is up to date
3. Must present a minute showing that you are willing to join the organization
4. Must present the names of their representatives to the organization
5. Must attach list of members, photocopies of their IDs and their signatures
6. Must adhere to the organization’s rules and regulations

GROUP DETAILS

Name of Group: …………………………………………………………………………………………………………

County: …………………………………………………………………………………………………………………….

Constituency: ……………………………………………………………………………………………………………

Location: ………………………………………………………………………………………………………………….

Email Address: …………………………………………………………………………………………………………

Group meeting days and venue: …………………………………………………………………………………

CONTACT PERSON

Name: …………………………………………………….. Signature: ………………………….

Chairperson

Tel No.: …………………………………………………… ID No.: ……………………………….

Name: …………………………………………………….. Signature: ………………………….

Secretary

Tel No.: …………………………………………………… ID No.: ……………………………….

Name: …………………………………………………….. Signature: ………………………….

Treasurer

Tel No.: …………………………………………………… ID No.: ……………………………….

Name: …………………………………………………….. Signature: ………………………….

Organizer

Tel No.: …………………………………………………… ID No.: ……………………………….

Our Aim is to respond to the growth needs to provide psychosocial, legal and economic support to the challenges
of the vulnerable members and the community they live in.
 GROUP FUNERAL EXPENSE

The policy is designed to meet the last expense in this extent of a demise of dependent.
The policy is an annual cover with renewal terms determined subjects to the scheme
performance.

SCOPE OF COVER

The policy provides for the following;

i) Benefit ranging from Kshs. 30,000/- to Kshs. 75,000/- depending on the

dependency that is lost.
ii) Annual premium is per the principal member
iii) Covers the principal spouse, children and parents
iv) Cover both accidents and natural death
v) Waiting period of the three (3) months after payments.
vi) Lump sum benefit payable in the event of death of the specified family
members ….
vii) The cover runs for one year and is renewable annually upon expiry

SCHEDULE OF BENEFITS

CATEGORY LUMP SUM BENEFIT (KSHS.)

Principal Member 75,000
Spouse 50,000
Parents 50,000
Children 30,000

Our Aim is to respond to the growth needs to provide psychosocial, legal and economic support to the challenges
of the vulnerable members and the community they live in.
 LAST RESPECT CLAIM FORM

Full Name of Deceased: ……………………………………………………………………………………………….

Date of Birth: ………………………………………………………………………………………………………………

Place of Death: …………………………………………………………………………………………………………….

Cause of Death: …………………………………………………………………………………………………………...

Date of Death: ……………………………………………………………………………………………………………..

Contributors Name: …………………………………………………………………………………………………….

DOCUMENTS REQUIRED

1. Copy of ID Card or Birth Certificate (For children of the deceased)

2. ID Copy of the Beneficiary
3. Police abstract for accidental deaths

I hereby confirm that all the information provided in this form and documents in
support of the claim are complete and true to the best of my knowledge.

Dated …………………………………………………

Full Name of Claimant: ………………………………………………………………………………………………...

Signature: …………………………………………………………………………………………………………………...

Name of Beneficiary: …………………………………………………………………………………………………..

Beneficiary ID No.: ……………………………………………………………………………………………………..

(Attach copy)

OFFICIAL USE

Agent’s Name: …………………………………………………. Sign: …………………………………….

Unit Manager’s Name: ……………………………………… Sign: ……………………………………..

Organization’s Manager Name: ………………………… Sign: ……………………………………..

OFFICIAL STAMP

Our Aim is to respond to the growth needs to provide psychosocial, legal and economic support to the challenges
of the vulnerable members and the community they live in.
 LAST EXPENSE REGISTRATION FORM
ID No: ……………………………………………………………………………………………………………………….
First Name: …………………………………………………………………………………………………………………
Middle Name: ……………………………………………………………………………………………………………...
Last Name: …………………………………………………………………………………………………………………
Date of Birth: ……………………………………………………………………………………………………………..
Gender: ……………………………………………………………………………………………………………………..
Marital Status: …………………………………………………………………………………………………………….
Postal Address: …………………………………………… Postal Code: ……………………………………
Place of Birth: ……………………………………………………………………………………………………………
County: ……………………………………………………….. City: ………………………………………………..
Mobile 1: ……………………………………………………… Mobile 2: ………………………………………….
Home Village: ……………………………………………………………………………………………………………...
Occupation: ……………………………………………….. Residence: …………………………………………..

DEPENDANTS (ADD +)

NO. NAMES RELATION COPY OF ID CARD BIRTH CERT COPY

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

NEXT OF KIN: ………………………………………………………………………………………………………………………….

NAME OF KIN: ………………………………………............. ID NO. OF KIN: ……………………………………….

SIGNATURE……………………………………………………..
Our Aim is to respond to the growth needs to provide psychosocial, legal and economic support to the challenges
of the vulnerable members and the community they live in.
 MEMBERSHIP FORM
Name of Applicant: ………………………………………………………………………………………………………………….
Date of Birth: …………………………………………………………………………………………………………………………..
Gender: ………………………………………………………………………………………………………………………………….
Address: ………………………………………………………….. Code: …………………………………………………….
Phone No.: ………………………………………………………… Mobile No.:……………………………………………..
Email: ……………………………………………………………….. Website: ………………………………………………..
Present Occupation: ……………………………………………………………………………………………………………….
If Student, write study level and Field: …………………………………………………………………………………….
Name and Address of Institution: ……………………………………………………………………………………………
Special Interest / Hobbies: ………………………………………………………………………………………………………
How did you come to know about the organization?:……………………………………………………………….
……………………………………………………………………………………………………………………………………………..
Type of Membership requested
Full Member: Life Time member:
Willingness to contribute towards Adullam Africa in support of providing Psychosocial, legal
and economic support. to the challenges of the vulnerable members and the community they
live in. I am Interested in being involved in the activities of Adullam Africa
(If YES in any of the two above questions please provided a more detailed explanation here)

I accept membership into Adullam Africa and the Standards are limited to persons of good
moral character and reputation. I recognize the acceptance of rendering personal services to my
community in cooperation with other civic minded persons. I understand that membership is
not valid until approved by the organization Board of Directors

Signature: ………………………………………………………… Date: …………………………………..

(FOR OFFICIAL USE ONLY)

SIGN: …………………………………………………. STAMP: ……………………………………………

Our Aim is to respond to the growth needs to provide psychosocial, legal and economic support to the challenges
of the vulnerable members and the community they live in.