‘With You every step oF hE Way
INDIVIDUAL LIFE ASSURANCE APPLICATION FORM
‘Please print clearly in BLOCK letters and ck () where appropiate,
4, APPLICANT'S/POLICY OWNER DETAILS (2s On National 10 or Passport)
() Personal Information
Tee: mr |tes [Zits | |other ease Spey
‘Summame: aan Gu) 4 Feaname PH YL LS
idse names: MYM bY A
on fe atoll G1 4 erect | _|vale _eale
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esr Numb: —
connyatrascace: — KEMY A warnnme Olas 26332 N
eras: shoe | _|varias Cer (rea Spat
Posi adress: fo LOA QIPS Postal Cade: cel.
Resident Aces: Kerk) Towmicy: Ge
robienunbe: OFFS () TH CL trot: Phy los myonbacy 0 Bergan [Ly]
refered Mead of Contact: | rat Teephone £
yuh or ave eer ed a pol or igh aking pub fee ‘es pj
Do your dose raterus pres hls or sever pla or Nchranking pb toe | Yes |
(i) Lite Proposed (Ifliferet from Policy Owner)
Name Retatinship to Petey Onrer
Dateorsity yt canter w]e]
(iy Premium Payer's Detaile® (Fifer ronybalcy Owner)
Name Tao Ne HRAFINNo
etatnship Poly Owner emi Prercan!btam eieege Nocnhaccee
(iv) Policy Owner's Ocx tion Details
employed Empuyes | |tnerpioed | |Retes omer (ene Sect)
Hat evga, sate dues ecoryouopentes: SALE ep pNEAS LARE
Town be fr ROB) soot KAmukuny, suing ZRAvElE es
1 employed, please provide the following information: reset Ccxpvion
oly Nae: EmployersAdbess
Employment Industry: Hospitamy — [| Putle Service/Goverment Education
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(0) Contact Person Details (Dai ar for contac anos nce we cnt ea he ts rv)
‘Name “Mobile Number Postal Address Postal Code | Town
Aut aweteht | 072 7— Ps Bux 29752 awe! Gpo
nan gud 523192 fF i
Pease ote Stam sees th ight sete oat or Soamenatn ene xref Be ed orem payment
ram Life Aacurance Company (Kenya) id ie eguatod by tho Insurance Regulator Auth & Retirement Benefits thoy (¥) Source of Funds for the Premium Payer
| |Rentaveropary sale [Salary Jordensymret | [Penson _|tnhetarce |i
| |teteyeening | sings | sale ot Shares an | matting invesrments
[oer (ease Spey
-NEFICIARY DETAILS.
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Einav Out Lape tat thes eto and request Sal rama Yrce afer ny Gath 2 wel as rr teria
19 The Company may recover ny expenses ince if Terinte the appa or insrence before the contact iscompkeed.
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12, APPLICANT SIGN-OFFOF TERNS AND CONDLONS, AND ATA PROTECTION ACT
Name of appicant: PE YL | re: ung Date: sofos Jeorye
se
onect wines: eeudcef yu mb Simatre Stats /Jos/eody 13. FOR BRITAM STAFF USE ONLY
13.1 Pease provide copies ofthe following:
a! certain Document or cure passpot or len 1D
_) Ta 8) Pt create
‘etisarettuinea? (“ves Cea
{7 te ete al sera Scon eo
13.2 Financial Advisor/Imermediary
{confi that al the above dunes have been ataced
oem EK ISEB hun p meu)
Mobile Number: Gor S61 185 enannazen
iuxGhina ante _/00 F529 spars
tame oF Manage
Moe number:
eck (Ontong and Cmplane)
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ee