Hekima Plan Form

Note: Please ensure that all the details submitted on this form are correct. In the event of a claim, any differences between the details herein
and those pertaining to the claim may result in a delay or rejection of the claim. The applicant must initiate any changes and corrections.
Please answer all questions.
POLICY NUMBER: AGENCY CODE:

Section A: Personal/Policyholder Details

Full Names as per ID:

F I R S T M I D D L E L A S T

Passport/ID No: Gender: Male Female

PIN No: Date of Birth: D D M M Y Y Y Y

Marital Status: Single Married Divorced Widowed

Telephone No: Postal Address:

Email Address: Postal Code:

Town: Employer:

Occupation: Monthly Income (Kshs):

Section B: Benefit & Premium Details

Policy Cover Details Term of policy (5 - 16 years) Basic Sum Assured Premium Payable
-(Minimum 500k)

Critical Illness* (30% of basic sum assured) Tick

PHCF Premium Amount (@ .25%)

Total Premium

Basic Sum Assured - the client can specify the desired sum assured and term, underwriting conditions apply.

Payment Frequency: Annual Semi-Annual Quarterly Monthly

Optional Critical Illness rider benefit - 30% of sum assured on the first diagnosis of any one of the pre-defined conditions.

What percentage would you like your sum assured to escalate on an annual basis? Please select the percentage.

0% 5% 7.5% 10% 15%

*Only one claim for this benefit is allowed after which the benefit will cease and no premium will be deducted for this benefit. The benefit is at 30% of the
main cover sum assured.

Section C: Nominated Beneficiaries Details

Beneficiary Name Identification number Gender - Male/Female Date of Birth Relationship to applicant Contacts Percentage

Guardian Details (Where the Beneficiary is below 18 years)

Guardian Name Identification number Gender - Male/Female Relationship Contacts

Please note that in the event of any modification or variation to the printed content of this standard form, Liberty Life Assurance Kenya Ltd will regard this form as being invalid and of no force and effect.
Do not sign blank or incomplete forms. Regulated by the Insurance Regulatory Authority

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 Section D: Payment Details

Mode of Payment: Cash/ Cheque Direct Debit Standing Order Salary Check-Off

Others (Specify):

If Debit Order Payments:

Account Type: Current Account Savings Account

Bank Name:

Account Number:

Branch Name: Branch Code:

Name of Account Holder:

Select a day of the month we can debit your account?

If Check-Off is selected:

Pay-roll Number:

Date of Employment: D D M M Y Y Y Y Start Date: D D M M Y Y Y Y

Section E: Declaration of health of the principal applicant

1. Do you travel in non-scheduled private flights? Yes/No

2. Do you engage in any hazardous sports such as mountain climbing, sky diving, bungee jumping, hang gliding, motor sports etc.? Yes/No

If yes, please give details

3. Name and address of your usual Medical Attendant / Medical Institution (or a Doctor who knows you through attendance on your family):

4. Have you been hospitalized or suffered from any illness, accident or disease during the last five years? Yes/No

i. If yes give details

ii. Give details and treatment of ailment or disease you have suffered from within the past five years

iii. Are you currently taking any medication or under medical observation? Yes/No

If yes give details

5. Are you and the proposed insured(s) now, in all respects, in good health? Yes/No If No give details

Please note that in the event of any modification or variation to the printed content of this standard form, Liberty Life Assurance Kenya Ltd will regard this form as being invalid and of no force and effect.
Do not sign blank or incomplete forms. Regulated by the Insurance Regulatory Authority

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 Section F: Declaration by the policyholder

This declaration contains guarantees and undertakings that I, as the Policyholder and the principal life assured agree to.
I confirm that I understand the product and policy:
• I confirm that I understand the nature of the product and that the Intermediary has explained the product rules, Terms and Conditions, and relevant
marketing material.
I guarantee that I am giving information correctly and to the best of my knowledge:
• The statements made in this application and in any other documentation submitted in connection with this application form the basis of the policy
applied for and shall constitute all representations made as a basis for the said policy. Where any material information is not fully disclosed, or is found to
be untrue, Liberty Life Assurance Kenya Ltd may decide to cancel the policy and/or not pay any claim or benefits.
I guarantee to keep my details up to date:
• I undertake to keep Liberty Life Assurance Kenya Ltd informed of any changes to the information supplied on this application, which includes but is not
limited to my contact details to enable Liberty Life Assurance Kenya Ltd to communicate with me.
I authorize Liberty Life Assurance Kenya Ltd and the authorized representative:
• To collect and process certain personal and financial information from me if relevant to my policy.
I authorize Liberty Life Assurance Kenya Ltd to collect and share information:
• I accept that with this authorization I am limiting my right to privacy. However to assess the insurance risk, I irreversibly authorize Liberty Life Assurance
Kenya Ltd.:
a. to obtain from any person, whom I hereby permit and request to give any information which Liberty Life needs, and
b. to share with other insurers that information, and any information in this application or any related source at any time, in a form approved by Liberty
Life Assurance Kenya Ltd.
It is further agreed that unless otherwise advised, the said policy shall only take effect if:-
a. It is accepted and delivered to the applicant and the first premium is paid in full to the company;
b. There has been no material change in the health or insurability of the life or lives proposed subsequent to the completion of this form.

Policyholder Name:

Signature: Date:

Details of Company’s Sales Representative

Life Agent / Unit Department:

Signature: Date:

Branch / Unit

Agency Manager Name:

Signature: Date:

Please note that in the event of any modification or variation to the printed content of this standard form, Liberty Life Assurance Kenya Ltd will regard this form as being invalid and of no force and effect.
Do not sign blank or incomplete forms. Regulated by the Insurance Regulatory Authority

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 Section G: Approvals

UNDERWRITTEN BY: APPROVED BY:

Name: Name:

Signature: Signature:

Date: Date:

OTHER OBSERVATIONS/ INSTRUCTIONS FROM THE UNDERWRITER

1) Additional Rating: 2) Medical Underwriting:

3) Financial Underwriting: 4) Needs Analysis:

Approved by:

Name:

Date: Signature:

Please note that in the event of any modification or variation to the printed content of this standard form, Liberty Life Assurance Kenya Ltd will regard this form as being invalid and of no force and effect.
Do not sign blank or incomplete forms. Regulated by the Insurance Regulatory Authority