Fidelity Guarantee | Proposal

Personal Details

Risk By Employer

Risk By Employee

General Policy Details

Personal Details

Proposer Type

Are You a Shareholder?

Intermediary

Agent Name/Code

Binder

ID Type

ID Number

TIN Number

Proposer First Name

Proposer Middle Name

Proposer Last Name

Is there any Care of/Account of/and?

Please specify name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

Is the insurance being purchased for self? (if no, state your details)

First Name

Middle Name

Last Name

Applicant Contact & Other Details

Contact Details

Mobile No.

Telephone No.

Fax No.

Region/City

Zone/Sub City

Woreda/District

Kebele

P.O. Box No.

H.No.

Email Address

Which Bunna Insurance S.C. branch do you want to be served from?

Physical Address

The Employee must provide an answer to the question below :

Employee's Details 1

Employee Name

Employee Address

Are you single or married?

How many children or other persons are wholly dependent upon you?

What are the duties in respect of which this guarantee is required?

State the nature and amount of any debts or of any other liabilities existing?

What are the applicant's (employee's) monthly salary or remuneration?

What are the deductions (if any) ?

Have you ever been bankrupted or insolvent?

Do you have any means of support in addition to the remuneration from the employment for which this Insurance is required?

Do you own building, vehicle or any other property?

How long have you lived at your present address?

Give the name, address and occupation of two references that are not related to, but have been intimately known to you in private life for some years, to which the Company may refer if necessary.

1 Reference Details

Name

Address

Profession / Occupation

How have you been occupied during the last five years?

1 Employer Details

Name

Address

Years

Activity

Do you want to upload employee excel by employee?

Download Fidelity Guarantee Employee Template Download Template

Excel

* Allowed file formats (xlsx)

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?

Required you to carry the first portion of any loss?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 3 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)

Fidelity Guarantee Proposal

Personal Details

Contact Details

Period of Insurance

The Employer must provide an answer to the question below :

Employee's Details 1

Employee Financial Details

The Employee must provide an answer to the question below :

Employee's Details 1

1 Reference Details

1 Employer Details

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION AND CONSENT | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *