Crop - Open field Proposal

Personal Details

Proposer Type

Bank Assurance Officer

Select Intermediary branch

Insurance Company

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 FBBI branch do you want to be served from?

Period of Insurance

Insurance Start Date

Insurance End Date

Describe your business or occupation

Farm Details

Location Details

LR No.

Village

Town

County

No of Years of Farming Experience of Proposer

Crop Details

Type of Crop

Variety

Past historical production

Year

Production per acre

Unit of measure

Add

Long Term Average Yield per year:

Planting Date

Harvesting Date

Area(in acre)

Planting Distance in cms (Plant to Plant)

Planting Distance in cms (Between Rows)

Agreed price per unit of measure

Age (for perennial only)

Sum Insured

Market Supplied

Local

Export

Rate

Did you suffer from any loss in the past 10 years?

Year

Crop

Area Planted (In Acre)

Area Destroyed (In Acre)

Cause/Perils

Please Specify(In case of other selected)

Remove

What do you consider to be the biggest threat to your crops?

Is there any active risk management implemented in the farm?

Perils

1. Fire

2. Pests

3. Disease

4. Hail

5. Excess Rainfall

6. Windstorm

7. Drought

8. Frost

Do you wish to indicate beneficiaries for your estate?

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?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 5 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

The liability of the Company does not attach until the proposal has been accepted, post germination inspection done by an appointed and approved agronomist and the premium paid.

DECLARATION | 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.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Family Bank Insurance Agency to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)