1

Personal Details

2

Risk Details

3

Additional Details

4

General Policy Details

Personal Details

Male Female

Contact Details

Period of Insurance

Other Details

Beneficiary Details

Beneficiary 1

General Policy Details

Has any insurance company ever

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 5 years

DECLARATION | Please Read Carefully *

I/ We do hereby declare that the above answers and statements are true and that I/ We have withheld no material information regarding this proposal. I/ We agree that this declaration and the answers given above as well as any proposal or declaration or statement made in writing by me/ us or anyone acting on my/ our behalf shall form the basis of the contract between me/ us and the Company. I/ We further agree to accept indemnity subject to the conditions in and endorsed on the Company’s policy.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Kenya Orient Insurance Limited to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)