Livestock Proposal

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

Period of Insurance

Insurance Start Date

Insurance End Date

Describe your business or occupation

Financier Interest Party

Financier Interest Party Branch

Farm Details

Village

Region/City

Zone/Sub City

Woreda/District

Experience and Qualification of Owner / Deputy / Key Staff:

Name

Designation

Qualification Level

Special Training

No. of years in Farm

Total Years Farming Experience

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Please select method to add items

Group of Animals

Excel

* Allowed file formats (xlsx)

Download Animal Template

Animal Details

Type of Animal

Breed

Tag Number

Name

Age In Years

Gender

Date Of Birth

Use of Animal

Number Of Animals

Proposed Value

Actual Proposed Value

Unique Identification Marks on the Animal

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Total Proposed Value (Max Total Proposed Value : 999999999)

Health Details

State major health problems encountered on the farm

Appointed veterinary surgeon of the farm

Full Name

Qualifications

Years responsible for this farm

Availability / Reachability

Vaccinations required by national legislation

What kind of vaccination program is applied for the different age groups of animals kept/raised?

Group of Animals

Vaccination Program

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How many animals have you lost in the previous one year ?

Group of Animals

Mortality(%)

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(Display Note: Stabling, open stabling, paddock, pastoral -Distance Range from Farm)

Stabling

Open Stabling

Coups

Houses

Paddock

Pastoral

Distance from Farm

Free Range

Other

Other Descriptions

Feeding practice/regime and source of feed and fodder?

PERILS
Accidental death due to lightning, internal and external injury, fire, windstorm, snakebites, flooding and electrocution.
Uncontrollable diseases and outbreaks
Difficulty during delivery ( Dystocia)
Emergency slaughter on the advice of a qualified veterinary surgeon as a result of accidents, illness and disease ( Euthanasia)
Theft by use of force when in a paddock or under zero grazing
Transit risks within a radius of 25 kms.

Are there other insurances for the same farm?

What do they cover?

Did you suffer from any loss in the past 5 years?

Year

Loss

Cause

Loss Value

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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)