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Insurance Cover Request Form
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Full Name of Insured (Individual/Company)
KRA PIN (Tax PIN)
Location / Address
Industry / Occupation
Email
Mobile Number (WhatsApp preferred)
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Golf
House
Travel
Motor
Marine
Health
Life
Other
Type of Cover Requested
Golf Insurance
Driver – Value
Irons – Value
Woods – Value
Putter – Value
Bag – Value
Buggy/Trolley – Value
Hole-in-One Cover
Personal Accident Cover
Personal Effects Loss
Personal Liability
Third Party Liability
Caddy Medical Expenses
If Golf Bag & Clubs are NEW – Amount
Upload Golf Receipt
House Insurance
Building Sum Insured
Year of Construction
Stone
Brick
Wood
Mixed
Other
Construction Type
Number of Floors
Owner-Occupied
Tenant
Mixed
Occupancy
Household Contents – Immovable
Upload Schedule of Immovable Items
Household Contents – Movables & All Risks
Upload Receipts for Movables
Number of Domestic Servants
Servant Roles
KSh/US$ 1M
2M
5M
Other
Personal Liability Limit
Travel Insurance
Traveler’s Full Name
Date of Departure
Date of Return
Country From → Country To
Upload Passport Copy
Motor Insurance
Vehicle Make, Model, Year
Reg. No.
Upload Logbook
Upload Valuation Report
Marine Insurance
Nature of Goods
Sea
Air
Land
Mode of Transport
Value of Goods
Upload Marine Documents
Health Insurance
Full Name(s) of Insured Person(s)
Age(s) & DOB(s)
Individual
Family
Corporate
Cover Type
Upload ID(s) or Health Documents
Life / Personal Accident Insurance
Insured’s Full Name
Date of Birth
Sum Assured
Beneficiary Details
I hereby declare that the information provided is true and complete. I understand that incomplete or false details may affect quotation and coverage.
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