Create | FBIA

Proposer Details

Life to be Assured

Plan Information

Health & Supplementary Questions

Family & Insurance History

Authority To Obtain Info

Personal Details

Insurance Company

Kenyan ID

First Name

Middle Name(s)

Last Name

Gender

Male Female

Date of Birth

Relationship to Life Assured

Customer Type

Occupation

Monthly Income

House Tel

Office Tel

Mobile No.

Physical Address

Postal Address

Postal Office

E-Mail

Which FBBI branch do you want to be served from?

Personal Details

Kenyan ID

Pin No.

First Name

Middle Name(s)

Last Name

Gender

Male Female

Date of Birth

Nationality

Marital Status

Contact Details

Physical Address

Postal Address

Postal Office

Mobile No.

House Tel

Office Tel

Occupation

Name and Address of Employer

Specific Duties

Employer E-Mail

Beneficiary Details

Beneficiary 1

Beneficiary Name

Date of Birth

Relationship to Life Assured

Share %

Guardian Mob No

Name of Guardian

Date of Birth

Relationship to Beneficiary

Plan Information Details

Generate Plan Information on the basis of:

Sum Assured Premium

Product Type

Product

Term

Premium Frequency

Basic Sum Assured

Basic Premium

Rider Information

Rider Name	Apply	Sum Assured	Premium	Type

Cover Type

Anticipated Payouts

S.No	Year	Amount

Cashback

Projected Bonus Percentage

Projected Bonus Amount

Tax Relief

Total Payout

Total Premium: KES 0

Payment Mode:

Payment mode for Refund:

Bank

Branch

Account No

Accout Name

Debit Date

Check off Group

Check-Off-Group

Start Month

Payroll No

Health Questions

Are you at present in good health?

Yes No

Please provide details

Have you consulted any doctor as an inpatient or outpatient in the last 3 years?

Yes No

Please provide details

Are you now pregnant? If Yes, how many weeks?

Yes No

Please provide details

Have you had an X-Ray, electrocardiogram or undertaken any medical tests within the past six (6) months?

Yes No

Please provide details

Are you currently on any medication?

Yes No

Please provide details

Have you ever had a serious injury that required critical care and or hospitalization?

Yes No

Please provide details

Have you suffered from, had symptoms of or been told by a medical practitioner that you had: (Tick appropriate item and give details where applicable)

Yes No

Please provide details

Dizziness, fainting, convulsions, epilepsy, paralysis, stroke or severe headaches?

Yes No

Please provide details

Depression, anxiety, Alzheimer's disease, mental or nervous disorder?

Yes No

Please provide details

Shortness of breath, bronchitis, emphysema, asthma, pleurisy, pneumonia, tuberculosis or persistent cough ?

Yes No

Please provide details

Chest pain, angina, palpitations, irregular heart beat, high blood pressure, heart attack, congestive heart failure or coronary artery disease ?

Yes No

Please provide details

Heart murmur, heart valve disorder, oedema or disorder of the heart or blood vessels?

Yes No

Please provide details

Ulcer, intestinal bleeding, colitis, ulcerative colitis, Crohn's disease, jaundice, hernia, diarrhoea, hepatitis or any disorder of the stomach, intestines, spleen, liver, or rectum ?

Yes No

Please provide details

Diabetes, high blood sugar or sugar in your urine?

Yes No

Please provide details

Blood or protein in your urine, any disorder of the kidneys, bladder, prostate or urinary system?

Yes No

Please provide details

Malaria, Black water Fever, or any other tropical diseases?

Yes No

Please provide details

Thyroid, thymus, pituitary or lymph gland disorder?

Yes No

Please provide details

Venereal disease or any disorder of the reproductive system?

Yes No

Please provide details

Cancer, sarcoidosis, tumour or any abnormal growth?

Yes No

Please provide details

Back pain, arthritis, muscular dystrophy or any disorder of the muscles, bones or joints?

Yes No

Please provide details

Back pain, arthritis, muscular dystrophy or any disorder of the muscles, bones or joints?

Yes No

Please provide details

Haemophilia, Sickle Cell anaemia, anaemia or any disorder of the blood?

Yes No

Please provide details

Any other condition or disease not mentioned above?

Yes No

Please provide details

Have you ever had or been advised to have a blood test for AIDS, AIDS related or immunological condition?

Yes No

Please provide details

Have you ever been refused as a blood donor?

Yes No

Please provide details

Have you ever received a blood transfusion within the last 5 years?

Yes No

Please provide details

Supplementary Questions

Height (Feet)

Height (Inches)

Weight(kg)

Have you lost/gained weight in the last two months?

Yes No

If YES give details of when the doctor was consulted and for what complaints.

If YES above, please state the amount and reasons for the gain or loss.

Have you any intention of engaging in any unusually hazardous circumstances which might affect this assurance(for example dangerous sports, student pilot, service in the armed forces, motor sports, aviation other than a fare paying passenger on a scheduled airline, water skiing, underwater diving, para - chuting gliding and mountain climbing or any other hazardous occupation, sport or pastime) ?

Yes No

If YES above, please give details.

Do you use intoxicating drink, tobacco or nicotine products or habit-forming drugs?

Yes No

Intoxicating Drink Frequency(Monthly)

Intoxicating Drink Quantity(ml)

Tobacco Frequency(Weekly)

Tobacco Quantity(mg)

Habit Forming Drugs Frequency(Weekly)

Habit Forming Drugs Quantity

Note: Enter '0' if do not consume.

Have you ever been convicted of a felony or misdemeanour within the last five (5) years or have any charges currently pending

Yes No

If YES above, please give details.

Family Details

Alive Deceased Single Parent

Age

State of Health

Reason/Cause of Death

Duration of Illness (months)

Mother Details

Alive Deceased Single Parent

Age

State of Health

Reason/Cause of Death

Duration of Illness (months)

Brother/Sister Details

Insurance Details

Have you ever applied for life insurance?

Yes No

Insurance Company

Policy Type

Proposal Date

Proposal or Policy Number

Sum Assured

Acceptance Terms(At Ordinary Rates, At Extra Premiums etc.)

Has a proposal on your life ever been declined, postponed, withdrawn or accepted on special terms?

Yes No

Insurance Company

Policy Type

Proposal Date

Sum Assured

Acceptance Terms(Declined, Postponed, withdrawn, accepted on special terms, etc.)

Authority To Obtain Details

Give the name and address of your personal doctor or medical facility where your medical records may be obtained:

Doctor Name

Doctor Address

Intermediary

I accept that I am curtailing my right of privacy, to facilitate the assessment of the risks, and the consideration of any benefits under a policy related to this or any other application for insurance made by me, or in respect of me as life to be assured and hence irrevocably authorise that:

any institution wherther insurance company, Association of Kenya Insurers Life Registry or any medical practitioner, hospital, clinic, medical facility; having any records pertaining to me or my health, to provide KOLAL or its reinsurers with any information sought, at any time(even after death)
information obtained with this authorisation may only be used as lawfully required, to determine insurability or as I may accept.

NOTE: Information regarding your insurability will be treated confidentially. We may however, make required reports to the Association of Kenya Insurers Life Registry and may also release information to other insurance companies to whom you apply for insurance or to whom a benefit claim may be reported.

Individual Life Proposal

Personal Details

Personal Details

Contact Details

Beneficiary Details

Beneficiary 1

Plan Information Details

Rider Information

Anticipated Payouts

Health Questions

Supplementary Questions

Family Details

Mother Details

Brother/Sister Details

Insurance Details

Authority To Obtain Details