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APPLICATION FORM - PRIVATE INSURANCE

This application form is optimised for use by Mobile SmartPhones

When Do You Want Insurance To Start*

/ / Invalid Input! The date is required: After today

Type of request

Kindly input Type of request

Type of Insurance*

Invalid Input! An insurance option is required

Preferred Insurance Company for Comprehensive*

Kindly choose your desired insurance company

Preferred Insurance Company for TPFT*

Kindly choose your desired insurance company

Preferred Insurance Company for TPO*

Kindly choose your desired insurance company

Duration of Insurance

Invalid Input! Duration of insurance required

MOTOR VEHICLE DETAILS

Year of Manufacture*

Kindly input the car's year of manufacture

Kindly note, for Comprehensive Insurance the maximum age at entry for a Motor Vehicle is 12 years

Car Manufacturer*

Please select a car Manufacturer

Car Model*

Please select a car model

If you do not know the Specific Car Model a close equivalent can do.

Car Price*

Invalid Input! The car value is required

Minimum amount is KES500,000.00 (Kindly input amount without a comma)

Motor Vehicle Number plate*

Kindly choose the month your car number plate

Does a Bank or Financial Service Provider have Financial Interest*

Invalid Input! Option required

Was the Motor Vehicle bought using a loan?

Bank Name for Financial Interest*

Choose the Bank Name

CLIENT DETAILS

The Motor Vehicle Ownership is:*

Invalid Input! Ownership category is required

Full Name*

Kindly input your names

Company

Invalid Input

Attach a copy of the Company Certificate of Incorporation

Invalid Input

P.O. Box

Invalid Input

KRA PIN*

Invalid Input! KRA PIN is mandatory

National Identification Number*

Invalid Input! National identification number is required

Attach a copy of the National Identification

Invalid Input

Date of Birth

/ / Kindly input your date of birth

Telephone Number

Invalid Input! Telephone number is required

Email Address

An email address is required

Pickup Location

Invalid Input

We provide door to door delivery in Mombasa and Nairobi

Pickup Location

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Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Pickup Location

Invalid Input

We provide door to door delivery in Mombasa and Nairobi

Pickup Location

Invalid Input

Pickup Location

Invalid Input

Do you have a (scanned) soft copy of the log book*

Yes

Invalid Input! Choose available options`

Upload log book

Invalid Input

A copy of the log book is a requirement for comprehensive insurance. Alternatively, you can enter the chassis and engine number

Chassis number*

Invalid Input! Chassis number is required

Engine number*

Invalid Input

BodaBoda Delivery

Invalid Input

Messenger Delivery Instructions for Complete Address (Physical Address):

Invalid Input

[Address 1, Address 2]:

Address 1 (Name of road, street) Example: Chiromo Lane
Address 2 (Name of building, and location in the building): Delta Corner Towers, 6th Floor

Contact Person for Delivery by Messenger

Invalid Input

Contact person for Messenger to call in case of errors

Choose a Location for Valuation

Invalid Input

Car Valuation is FREE Required documents are Copy of Logbook (or Bill of Lading) and Ownership documents (National ID/Certificate of Incorporation)

UNDERWRITING DETAILS

Do you wish to use the Standard or Customised Underwriting Benefits Options

Invalid Input

Death and Accidental Permanent Total Disablement

Invalid Input

Free Death and Accidental Permanent Total Disablement upto KES 100,000

Named Driver for Personal Accident

A name is required, otherwise

Protection and Removal in respect of any one accident*

Invalid Input

Free Protection and Removal in respect of any one accident upto KES 30,000

Authority to Repair in respect of any one accident*

Invalid Input

Free Authority to Repair in respect of any one accident upto KES 30,000

Car Entertainement Unit in respect of any one accident

Invalid Input

Free Car Entertainement Unit in respect of any one accident upto KES 30,000

Medical Expenses in respect of any one accident*

Invalid Input

Free Medical Expenses in respect of any one accident upto KES 30,000

Windscreen and Windowglass in respect of any one accident*

Invalid Input

Free Windscreen and Windowglass in respect of any one accident upto KES 30,000

Loss of Use (Rental car in case of accident)

Invalid Input

Key replacement*

Invalid Input

FREE Key replacement upto KES 10,000

ATM Robbery following a hijacking*

Invalid Input

FREE ATM Robbery following a hijacking upto KES 10,000

Overnight accomodation expenses after accident*

Invalid Input

Physical Address will be required if this option is taken

Loss of Personal Effects*

Invalid Input

Legal Defence

Invalid Input

Legal Defence for insured and authorized driver for litigation under the Road Act (Excluding Fines in addition to liabilities to third party

Liability to Third Parties, Death of or Bodily injury in respect of any person (except where the death or injury arises out of and in the course of employment) being carried in or upon entering or getting onto or alighting from the motor vehicle:

i. In respect of any one person*

Invalid Input

ii. In respect of a series of claims arising out of one event*

Invalid Input

Road Rescue Services

Invalid Input

Extended Warranty

Invalid Input

Unexpected mechanical or electrical failure after Manufacturer's warranty has expired

Total Cost (Premium)

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PAYMENT INFORMATION

NOTE, THE INSURANCE ACT REQUIRES THE PAYMENT OF PREMIUMS AT INCEPTION OR RENEWAL DATE OF THE POLICY (CASH CARRY).
INSURANCE CLAIMS SHALL NOT BE PAID IF ANY PREMIUMS ARE OUTSTANDING

NINO Lipa Na BuyGoods Number

Total Amount To Pay

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Total Amount Paid*

Invalid Input! Do not include any comma (Eg: 1000)

MPESA Transaction Number*

Invalid Input

Additional Information

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If you have a specific question, kindly ask us through here, the additional options