WIBA PlusProposal

Personal Details

Risk Details

Other 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?

Period of Insurance

Insurance Start Date

Insurance End Date

Corporate Headquarter Detail

Name of Building

Name of Street

Please Note that the truth of the statements and answers in the proposal are conditions precedent to liability

Please list any laws or regulations that apply to the governance of your premises

Do you handle or use any of the following at your Premises?

Circular saws or other machinery driven by steam, gas, water, electricity or mechanical power

Provide Details

Boilers

Provide Details

Acids, gases, chemicals or explosives

Provide Details

Radioactive substances

Provide Details

Note: It is a condition of this Policy that the Estimated Annual Wages, Salaries and other Earnings is required to be certified annually by your Auditors within three months of the expiry date of the period of Insurance.

Employee Details

Occupation

No Of Employees

Type of Income

Estimated Salary (Per Employee)

Estimated Annual Salary (Per Employee)

Total Earnings

Occupation Description

Remove

Sum(Total Earnings) (Max Total Earnings : 999999999999)

Do you have any employee with any pre- existing medical condition?

Name

Occupation

Description of medical condition

Type of Income

Estimated Salary (Per Employee)

Estimated Annual Salary (Per Employee)

Occupation Description

Remove

Total Estimated Annual Salary (Max Total Estimated Annual Salary : 999999999999)

Do you have any employee who is an Apprentice or Trainee?

Name

Occupation

Type of Income

Estimated Salary (Per Employee)

Estimated Annual Salary (Per Employee)

Occupation Description

Remove

Total Estimated Annual Salary (Max Total Estimated Annual Salary : 999999999999)

Human Resource Contact Information

Mobile No.

Email address

Remove

Do you have any other policy from KOIL(Kenya Orient Insurance Limited)?

Employee Details Template

Upload Document

Download Template

Claim history

Did you have any claim in last 3 years

Year

Wages, salaries and other earnings

Claim settled total

Number of accident to your employees(whether or not involving claims)

WIBA Plus Proposal

Personal Details

Contact Details

Period of Insurance

Corporate Headquarter Detail

Do you handle or use any of the following at your Premises?

Employee Details

Human Resource Contact Information

Employee Details Template

Upload Document

Claim history