Intermediary Application Form

Personal Details

Intermediary Type

Application Type

Bank Associated

Associated Branch

Bank Name*	Koil Branch*	Action

Associated Branch

Branch*	Associate Koil Branch*	Action

IRA Registration Number

Intermediary Details

Full Business Name

Mobile No.

Email ID

Postal Office

Town

Physical Address

PIN No.

Intermediary Office Address

Building

Plot Number

Which Kenya Orient Branch do you wish to trade?

Branch Name

Name/s of Partner/s or Share Holder/s

ShareHolder Name *	Pin *	Email *	Contact No *	Actions

Is it alright with you if we contact your clients directly ?

Do you have any other business besides insurance ?

Have you represented other insurance companies ?

Previous Company Name *	Previous Company Start Date *	Previous Company End Date *	Previous Company Reason of Termination *	Actions

Staff Details

1-Principal Officer Contacts *

2-Staff name who will be responsible for insurance matters in your organization

Staff Name *	Is Experience	Years of Experience	Qualification*	Email Id *	Contact No *	Action

Premium Produced

Mode of Communication ?

In which area(s) of Kenya do you wish to operate ?

In which other countries do you have operation or business?

How much premium income have you produced in the last three years ?

CATEGORY *	Last Three Years *	Amount *	Actions

How much can you produce for Kenya Orient Insurance Limited in :

CATEGORY *	Year *	Amount *	Actions

Bank Details

Bank Name

Branch Name

Account Name

Bank Account Number

Reference Details

Please give the names, designations and addresses of two referees from the insurance industry (Not related to you) to whom referenced can be made

Please enter reference details

COMPANY NAME *	CONTACT PERSON *	DESIGNATION *	CONTACT NO *	ADDRESS *

Account Opening Application Form

Personal Details

Associated Branch

Associated Branch

Intermediary Details

Intermediary Office Address

Which Kenya Orient Branch do you wish to trade?

Name/s of Partner/s or Share Holder/s

Staff Details

Premium Produced

How much premium income have you produced in the last three years ?

How much can you produce for Kenya Orient Insurance Limited in :

Bank Details

Reference Details