Proposal Number:

ELIMISHA PLUS POLICY

PERSONAL DETAILS OF POLICY OWNER

Name (as in identification document) Title Gender

Occupation Marital Status Nationality Date of Birth

ID Number KRA PIN No. Passport No. Passport Expiry Date

Primary Mobile Citizen 1

Number Email Address
Citizen 2
Residence 1 Residence 2 P.O. Box Town Code

Physical address: Building/Village Street/Location Town County

US Citizens Only: Street City/State ZIP Code TIN Number

CHILD DETAILS (For Education Policy Only)

Name (as in identification document) Date of Birth

Relation ship to Life Assured Birth Cert No Gender

EMPLOYMENT/BUSINESS DETAILS
Business Name/Employer Nature of Business/Employee No

Role of proposer in business Employment Terms: Temporary Permanent Contract

PREMIUM DETAILS ( Benefit premium is calculated as rate/1,000 x sum assured)

Product Name Term (Years) Rate Sum Assured Premium Policy Fee PHCL Total Premium

Premium Payment Method Check-off Direct Debit Fosa Cheques (Non Monthly cases only)

Premium Payment Frequency Monthly Quarterly Semi-Annually Annually

PREMIUM PAYER DETAILS ( If different from policy owner)

Name ( as in identification document) Title Gender

Date of Birth ID Number Relationship to policy owner

BENEFICIARIES (Appointment of a minor may delay the settlement of the claim)

First Names Surname ID Number Date of Birth Relationship Gender Cell Phone no. Share %

GUARDIAN (For Minor beneficiaries i.e Below 18yrs)

Name ( as in identification document) ID no. Date of Birth Relationship to Minor Gender Cell Phone Title

Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority

www.kcbgroup.com/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 [email protected] Paybill No.: 522666 Paybill No.: 522666
 FINANCIAL QUESTIONAIRE
Gross Income KShs Net Monthly Income Source of Income

OCCUPATIONAL AND RECREATIONAL HAZARDS/INSURANCE HISTORY

Has any proposal for life insurance cover on your life ever been made, or is now being made (excluding this application)?

Yes No If YES, please state:

Name of Insurer Year of Proposal Sum Assured Type of insurance Policy Status

Do you have any intentions of :

Yes No

Yes No

Yes No

Yes No

Yes No

FAMILY HISTORY (Optional)

Family History Age If Living State Of Health Age At Death Cause Of Death
Father

Mother
Husband/Wife

Children
Brother/Sister

STATEMENT OF HEALTH OF THE LIFE ASSURED:

This section covers your medical history. Please read the following questions and provide as much as information as possible. If the answer to any of the question
is YES, give full details regarding the Nature of complaint or symptoms, Type of treatment or medication, Date of first symptoms or diagnosis, Date of last
symptoms, Name and telephone number of attending doctor. If space provided is inadequate, attach a separate sheet, date and sign it.
1. Has an application for life, sickness, disability orcritical illness insurance on your life ever been declined, deferred withdrawn or
accepted with a loading or exclusion?_________________________________________________________________________________________ Yes No
2. Have you consulted or currently consulting or intend to consult in future a medical professional for any disease or medical condition
other than cold or flu?______________________________________________________________________________________________________Yes No

3.
Yes No
(b) asthma, tuberculosis, chronic cough______________________________________________________________________________________ Yes No
(c) heart attack, heart disease or disorder, high blood pressure, raised cholesterol ____________________________________________________ Yes No
(d) diabetes, stroke ______________________________________________________________________________________________________ Yes No
(e) cancer, tumours (state of benign or malignant______________________________________________________________________________ Yes No
(f) kidney disease, blood or protein in the urine________________________________________________________________________________ Yes No
(g) HIV/AIDS or HIV/AIDS related conditions, Sexually Transmitted Diseases (STDs) ___________________________________________________ Yes No
(h) psychological problems or disability ______________________________________________________________________________________ Yes No
(i) body or limb defects, paralysis, physical disability ___________________________________________________________________________ Yes No
(j) Have you been treated for or counseled or intend to be treated for or counseled for alcohol and drug use, dependency,
addiction or abuse? __________________________________________________________________________________________________ Yes No

4. What is your height? Ft ______ Ins _____ What is your weight? _____ Kg’s Is your weight Stationary? Increasing? Decreasing?

You are required to tell us anything that you may know about your health that may affect our decision to insure you. If you do not provide this information you
may not be able to claim the risk benefits under this policy or claim maybe declined

Replacement Question
Important Note: Replacement Of Any Assurance May Be To The Disadvantage Of The Policyholder Because It Involves Duplication Of Initial Costs Charged To The
Contract(If “Yes”, the agent must discuss and obtain written consent from you.)Is this application to replace the whole or any part of your existing insurance with
any assurer (whether replacement is to occur immediately or to replace an insurance discontinued within the past four months or within the next four months)?
Yes No

Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority

www.kcbgroup.com/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 [email protected] Paybill No.: 522666 Paybill No.: 522666
 Disclosure Checklist – Agent
The applicant has the right to the following information. Kindly confirm that this has been provided. (Please Tick Yes or No)
1.Have you provided the following information to the applicant
(a)Your full name and title?___________________________________________________________________________________________Yes No
(b) Office details(physical and postal address)?_________________________________________________________________________Yes No
(c)Telephone and email contact details?_______________________________________________________________________________Yes No
2. (a) Have you taken the circumstances of the applicant into account in order to satisfy their financial needs ________________Yes No
(b) Have you done a sufficient needs analysis?_________________________________________________________________________ Yes No
3.Have you disclosed the following information to the applicant:
(a)Type, extent and limitations of benefits_____________________________________________________________________________ Yes No
(b)That commission is payable on this policy and answered any commission-related questions?___________________________ Yes No
(c) The 28-day cooling-off period?_____________________________________________________________________________________Yes No
(d) Claims notification procedure?_____________________________________________________________________________________Yes No
(e)Cancellation procedure and surrender?______________________________________________________________________________Yes No
4.Is the applicant satisfied with the advice and disclosure that you have given?_______________________________________________Yes No
5.Has the applicant completed and signed the application form?____________________________________________________________Yes No

Channel of Distribution: Sanlam Life KBIL NBIL

AGENT DECLARATION

I hereby declare that I have explained the contract and the meaning and implications of replacements to the life to be assured and that
I am fully aware of the possible detrimental consequences of the replacement of any insurance contract. I declare that all the
information contained in this proposal was obtained from the life to be assured and was completed in his/her presence.

Name of Agent Agent's Code

Signature Date

Name of Sales Manager Branch

Signature Date

IMPORTANT NOTICE TO APPLICANT

No agent or staff of Sanlam Life is authorised to recieve cash on behalf of the institution. All premium payments by cash must be banked
into the company’s account provided for this purpose or paid into the company’s M-Pesa pay bill nuber 120120. Sanlam Life shall not be
liable for any cash given to a staff or agent.

DECLARATION BY APPLICANT/POLICY OWNER

I, _________________________________________________, the applicant and Policy Owner hereby declare, acknowledge, understand and agree
that:

Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority

www.kcbgroup.com/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 [email protected] Paybill No.: 522666 Paybill No.: 522666
 DATA PRIVACY NOTICE

I/We agree that Sanlam Life Insurance Limited (“Sanlam”) and KCB Group (“KCB”) will:
(i) collect, and process my/our personal data for purposes that are relevant to my/our policy and as permitted by law. The collection and
processing of my/our personal data is in accordance with the privacy statement on Sanlam’s website
(https://www.sanlam.com/kenya/privacypolicy/Pages/default.aspx) and KCB’s website
(https://ke.kcbgroup.com/data-privacy-statement );

(ii) ensure that it fulfills my/our rights as a data subject, which include my right to:
(a) be informed of the use to which my/our personal data is to be put.
(b) access my/our personal data in custody of Sanlam.
(c) object to the processing of all or part of my/our personal data.
(d) correction of false or misleading data about me/ourselves; and
(e) deletion of false or misleading data about me/ourselves

(iii) transfer my/our personal data to your reinsurers, other insurance companies, regulatory agencies, and affiliated
companies/parties for the purposes of my/our policy and as permitted by law.

(iv) transfer my/our personal data to Sanlam’s contracted third parties for purposes of contact you via email/phone
call/SMS/post regarding my/our policy; and

(v) ensure that there are technical and organisational security measures taken to ensure the integrity and confidentiality of the data

I/We understand the collection and processing of my/our personal data is mandatory for purposes that are relevant to my/our policy and as
by law. If I/We do not provide all the requisite personal data, Sanlam will be unable to fulfill its obligations to me/ourselves under the policy

For any inquiries relating to the processing of your personal data by Sanlam, please feel free to reach out to us through
[email protected] or [email protected]

Client Name/Scheme Name Policy Number

ID Number Designation/Position

Cell No/Landline Email Address

Date Sign

Stamp (For Corporates)

Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority

www.kcbgroup.com/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 [email protected] Paybill No.: 522666 Paybill No.: 522666