Kenindia Assurance Company Limited
(INCORPORATED IN KENYA)
Declaration Of Health And Habits
Full name: Date of birth: Policy/ Proposal no.
(Dd/mm/yy) (Write New for new proposals)
Identity Number Height (cm) Weight (Kg)
The client’s declaration as hereunder should be completed by the person to be assured only.
Please answer each question and where the answer is “Yes” provide details overleaf-duly signed--
-
1) Have you till date ever suffered from any mental or physical
Impairments or deformities needing medication or any surgical intervention Yes/No
2) During the last 5 years have you been medically examined, received medical advice
Or treatment or been in hospital for any illness, injury or disability Yes/No
3) Have you ever had persistent night sweats, chronic or frequent diarrhoea, unexplained weight loss,
persistent cough, skin disorder or recurrent or persistent fever? Yes/No
4) Have you ever been refused as a blood donor Yes/No
5). Have you received any blood transfusions within the last five years Yes/No
6) Have you ever suffered from any of the disease related to heart, respiratory
System kidney, eyes nose, throat, diabetes, orthopaedic or brain system Yes/No
7) Have you ever sought consultations or treatment for AIDS or an AIDS related
Condition Yes/No
8) Have you , and to the best of your knowledge your spouse or partner ever undertaken any consultation
, tests or treatment for Hepatitis B, HIV, or any sexually transmitted disease related disorders
Yes/No
9) Has any proposal for life assurance on your life ever been declined, postponed or
Accepted on special terms Yes/No
10) This particular question No. 10 is to be replied by Female lives only
Date of Last Menstruation Date of last delivery
Any previous miscarriage or Are you pregnant now Yes/No
Any irregularity in regular menstrual periods or any disease of breast ovary or uterus Yes/No
I confirm that all of the above answers and statements are true and even other than the above
asked specific question no material facts concerning my past present state of health and habits
have been withheld or omitted. I also agree that any doctor, whether named above or not who has
attended or examined me or who may do so hereafter shall be and is hereby authorized and
directed by me to disclose to the company any information he may have acquired with regard to
myself. I also declare that I do not intend to fly other than fare paying passenger and in any other
hazardous profession or hobby and declare that this supplementary declarations together with
the proposal dated ________________shall form part of the contract between me and the company.
Name and signature of person to be assured Date_________ Place______________
e- mail address - Telephone number -
Following declaration of Agent/ Broker is required for New Business Cases Only
I have personally met the above client and explained that the replies to above questions and
proposal would form the basis of terms and conditions of the contract. Having been personally
satisfied of the correctness of the information submitted by the client, I recommend for the
acceptance of this proposal (if acceptance is not recommended strike out the words I recommend
and give details on back of this paper duly signed)
10th Floor Kenindia House, [Link] 30377, Nairobi. Tel: 316099/2248719/2214439 Fax: 2242515
Em@il:life@[Link] A member of the Association of Kenya Insurers Website:[Link]
Kenindia Assurance Company Limited
(INCORPORATED IN KENYA)
Name and signature of the Agent/Broker Date_________ Place______________
10th Floor Kenindia House, [Link] 30377, Nairobi. Tel: 316099/2248719/2214439 Fax: 2242515
Em@il:life@[Link] A member of the Association of Kenya Insurers Website:[Link]
