1

Personal Details

2

Risk Details

3

General Policy Details

Personal Details

Male Female

Contact Details

Particulars of Vessel to be Insured

Note: Ship must comform to Lloyd’s Register of Shipping standards and/or Bunna Insurance S.C. Maritime Authority standards and any other governmental regulating bodies to ensure that the vessel has necessary structural strength for assigning a load line, and the issuing of a safety construction certificate.

Type of Fire Extinguishers and Number Carried

Captain/Master/Pilot Detail

Captain/Master/Pilot 1

Crew Details

Crew 1

Limits of Liability(ETB)

Limit of Indemnity For any One Accident

Maintenance Of The Vessel (Laid up, In Commission, Overhauling)



General Policy Details

Has any insurance company ever

Insurance and Loss History

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

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)