Create | KOIL

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?

Cover Type

Insurance Start Date

Insurance End Date

Please indicate whether you operate as a (tick as appropriate):

Sole Trade

Partnership

Limited Company

Describe your business or occupation

Name the main types of goods likely to be carried, handled and/or warehoused by you.

What is your area of Operations (Geographical area covered)?

Particulars of vehicles

Indicate whether the vehicles are

Owned

Hired

Owned And Hired

Vehicle Details

Trailers Details

Do you maintain a detailed register of all the vehicles that are used for carriage of goods?

Do you ensure that the vehicle(s) are regularly serviced and maintained in a road worthy condition at all times?

How do you ensure safety of the goods when the vehicle(s) are temporarily garaged during transit?

Employee Details

State the total number of own employees engaged

State the total number of hired drivers/operators

Do you have a system of vetting employees for trustworthiness before employment?

Do you verify validity of all drivers’ licenses and identities before engaging them in employment?

Please Explain

Insurance Details

Do you subcontract any carriage?

Do you have written contracts with the subcontractors?

How do you hold subcontractors responsible for any goods entrusted to them?

See Details Below

Selection Of Goods

Goods Name

How are the goods being transported

Limit of Liability (Single carry)

Limit of Liability (Estimated annual carry)

Single carry rate

Estimated annual carry rate

Provide your actual annual carry for each of the last three years:

Do you wish to purchase any of the following cover extensions?

Riot and strike

Political violence and terrorism

Hold Up and Hijack extension

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)

Carriers Liability Proposal

Personal Details

Contact Details

Please indicate whether you operate as a (tick as appropriate):

Particulars of vehicles

Vehicle Details

Trailers Details

Employee Details

Insurance Details

See Details Below

Provide your actual annual carry for each of the last three years:

Do you wish to purchase any of the following cover extensions?

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION AND CONSENT | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *