Orient Jipange Smart Proposal Form

  • Personal Details
  • Members Covered
  • Plan Information

Personal Details



P.O. Box

Names of family members covered

Name Date of Birth Relationship to Life Assured
Self

Names of next of kin

Name Date of Birth Relationship to Life Assured Mobile No.

Check your plan limit below

Plan Option Persons Covered Burial Expenses Monthly Shopping No claim Cash Back Monthly Premium
A
Self
Spouse
Each Child
Kshs. 15000 /-
Kshs. 15000 /-
Kshs. 8000 /-
Kshs. 3000 /-
Kshs. 3000 /-
Kshs. 15000 /-

Kshs. 228 /-

B
Self
Spouse
Each Child
Kshs. 25000 /-
Kshs. 25000 /-
Kshs. 10000 /-
Kshs. 4000 /-
Kshs. 4000 /-
Kshs. 25000 /-

Kshs. 368 /-

C
Self
Spouse
Each Child
Kshs. 50000 /-
Kshs. 50000 /-
Kshs. 20000 /-
Kshs. 8000 /-
Kshs. 8000 /-
Kshs. 50000 /-

Kshs. 732 /-