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Motor Vehicle Proposal Form
APPLICATION FORM
Step
1
of
4
- Client Details
0%
Name
(Required)
Surname Name
First Name
Last Name
Address
(Required)
Postal Code
(Required)
Phone Number
(Required)
Email
(Required)
ID No.
(Required)
KRA Pin
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Period of Insurance: From
(Required)
DD slash MM slash YYYY
To
(Required)
DD slash MM slash YYYY
Type of Policy
(Required)
Comprehensive Insurance
Third Party Only Insurance
Third Party, Fire & Theft
Class of Cover
(Required)
Motor Private
Motor Commercial
Motor Commercial PSV
Motor Cycle
Motor Tractor
Estimated Value of Vehicle
(Required)
Registration Number
(Required)
Make
(Required)
Model
(Required)
Chasis Number
(Required)
Body Type
(Required)
Year of Manufacture
(Required)
Engine Capacity (cc)
(Required)
Number of Seats
(Required)
Date of Purchase
Sum Insured
(Required)
Has the Motor vehicle(s) proposed for insurance been modified or altered in any way?
(Required)
Yes
No
If Yes, give details of modifications:
Is Anti-Theft Device fitted?
Yes
No
If Yes, Attach certificate on submission.
Max. file size: 90 MB.
Excess Cover
Yes
No
Personal Accident Cover for Driver
Yes
No
If Yes, Enter Cover Amount (Sum Insured)
Windscreen Cover > 30,000
Yes
No
10% of Extra Limit.
Radio Cassette limit > 30,000
Yes
No
10% of Extra Limit.
Riot, strike & perils
Yes
No
Additional premium of 0.25% of value.
Political violence, terrorism and strike
Yes
No
Additional premium of 0.45% of value.
Alternative car up to Kes. 30,000
Yes
No
Add premium of 3000 per vehicle. Only cars above of 1,000,000 value.
Required Documents (ID copies)
Drop files here or
Select files
Max. file size: 90 MB.
Excess
I/we hereby agree to accept this policy subject to the following restrictions:
• 2.5% of value, minimum 10,000 of each claim
• 10% of Value, minimum 20,000 of each claim for theft with anti-theft device
• 20% of value, minimum 20,000 of each claim for theft without anti-theft device.
Declaration
Agree to accept this policy
I hereby declare that to the best of my knowledge, the above statements and particulars given in this proposal are true and complete, that I have not withheld any material information and that the vehicles described is/are in good condition. I hereby further agree that this proposal and declaration shall be the basis of the contract between me/us and Einsurance Brokers Limited whose policy is applicable to this insurance. I am willing to accept the policy document subject to the above terms, exceptions and conditions prescribed by Einsurance Brokers Limited therein.
Client Signature
Date
DD slash MM slash YYYY
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