Machinery Breakdown LOPProposal

Personal Details

Risk Details

General Policy Details

Personal Details

Proposer Type

Intermediary

Select Intermediary branch

Binder

ID Type

ID Number

KRA Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Which Kenya Orient branch do you want to be served from?

Do you have a Machinery Breakdown from Kenya Orient Insurance Limited?

Insurance Start Date

Insurance End Date

Financier Interest

Do you have a Fire Insurance policy?

Policy Number

Start date

End date

Do you have a Fire Conloss Insurance policy?

Policy Number

Start date

End date

Building Details

1. Location Details

L.R No

Street

Area

Postal Office

Town

County

Building Details

Building Name

External Walls

Construction Roof

What works of your business are to be insured against Machinery Breakdown Loss of Profits?

Do you get your firms’ accounting records audited?

Name of Auditor / Chartered Accountant

Address of Auditor / Chartered Accountant

Intervals in which audited

When was the firm established?

Since when has the works to be insured existed?

Since when has the present production method used in the works to be insured been applied?

What interruptions due to a machinery loss have occurred in the works to be insured during the last 5 years?

Description of incidents

Year

Duration

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What type of repair work can be carried out without external help?

Please provide details of external repair facilities for the individual machines in the list of machinery.

Name of Machinery

Name of external repair facility

Address of external repair facility

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What maintenance work and what inspections are carried out regularly to keep the machines to be insured in good working order?

Type of maintenance:

Intervals at which done

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Are there any seasonal production or sales fluctuations of more than 20% in the works to be insured?

Month in which there is fluctuation

Percentage of fluctuation

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Is there a stock of semi-finished or finished products?

What period of interruption can be accomplished thereby?

Are there supplies furnished against letters of credit?

Please indicate the percentage such supplies have in the turnover

In the case of Machinery damage, is the interruption period longer than the repair period for the machinery involved?

Cause

Duration

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Machinery Details

Machine name

Description

Year of Manufacture

Relative Importance

Spare parts availability

Replacement period for machine in case of breakdown

Loss minimization measures put in place

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Insurance details

Profit details

Operating profits for the previous year

Standing charges for 12 successive months of business

Gross Profits

Indemnity period(In months)

Do you require time excess?

Please select the period of time excess required

General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Insurance and Loss History

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

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION AND CONSENT | 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.

I/We consent to Kenya Orient Insurance Kenya Ltd; (i) Collecting, using, disclosing and/or processing my/our personal data; and (ii) Transferring my/our personal data to their reinsurers and affiliated companies for the purposes of insurance as permitted by law.

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)

Machinery Breakdown LOP Proposal

Personal Details

Contact Details

Building Details

1. Location Details

Building Details

Please provide details of external repair facilities for the individual machines in the list of machinery.

What maintenance work and what inspections are carried out regularly to keep the machines to be insured in good working order?

Machinery Details

Insurance details

Profit details

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION AND CONSENT | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *