Goods In Transit

Personal Details

Risk Details

General Policy Details

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

Cover Types

Insurance Start Date

Insurance End Date

Describe your business or occupation

Will you transport any of the following?

Mode of Conveyance

Provide the below information (Note: At least one of the country must be “Kenya”.)

Point of loading? *

Point of Off-loading? *

Country

Town of Contact Work

Town

Country

Town of Contact Work

Town

Security of Vehicle

Do you ensure safety of the goods when the vehicle(s) are temporarily garaged during transit?

Please explain

Particulars of Vehicle *

Indicate whether the vehicles are (tick as appropriate)

Hired

Owned

Owned and Hired

Vehicle Details

If cover is required on specified vehicles, please complete the schedule below.

Registration No.

Make

Model

Carry Capacity (Tonnage)

Security details

Any Other Devices

Trailer Details

If cover is required on specified vehicles, please complete the schedule below

Registration No.

Make

Model

Carry Capacity (Tonnage)

Security details

Any Other Devices

Limit of Liability

Selection of Goods

How are the goods being transported?

Any one Carry

Estimated Annual Carry

What is the basis of valuation of the Goods?

Description of Property/Goods?

How will the goods be packaged whilst Transporting?

Do you wish to purchase these?

Riot and Strike

Political Violence and Terrorism

Hold Up and Hijack Extension

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

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)

Goods In Transit Proposal

Personal Details

Contact Details

Period of Insurance

Vehicle Details

Trailer Details

Limit of Liability

General Policy Details

Has any insurance company ever

Insurance and Loss History

DECLARATION | Please Read Carefully *

CREDIT INFORMATION | Please Read Carefully *