Agency Banking Proposal

PERSONAL DETAILS

RISK DETAILS

GENERAL POLICY DETAILS

Personal Details

Proposer Type

Intermediary

Select Intermediary branch

Binder

ID Type

KRA Pin KRA Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Date Of Birth

Gender

Male Female

If insured name or other name

Quotation Valid Days

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Which branch do you want to be served from?

Risk details

Name of the building	Location (L.R.No)*	Street*	Area*	Town*

Business/Trade/Occupation

Financier Interest Party

Bank details

Bank Name

Bank Branch

Period of Insurance

Insurance Start Date

Insurance End Date

Cover Type

Select Cover

Fire Section

Fire Sum Insured

Fire Building	Stock in trade	Furniture fixture and fitting	Office equipment	Others

Burglary section

Burglary sum insured

Please, provide information of Staff Members

Name *	Position *	Access to Safe / Cash Box / Drawer

Please provide information on the lockable device in which cash is stored

Note: Cash on the business premises must be stored in a lockable device at all times

Safe

Cash box

Drawer

Maximum amount of money held at any one time per emp.

How often is money collected from the bank?

How often is money taken to the bank?

What mode of transport is used to carry money to and from the bank?

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 AND CONSENT | 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.

I/We consent to Trident Insurance Company Ltd; (i) Collecting, using, disclosing and/or processing my/our personal data; and (ii) Transferring my/our personal data to their reinsurers and affiliated companies for the purposes of insurance as permitted by law.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Trident Insurance Limited to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)