Orient Jipange Smart Proposal Form

Intermediary

Kenyan ID

Pin No.

Male Female

First Name

Middle Name(s)

Last Name

Date of Birth

Mobile No.

E-Mail

Physical Address

P.O. Box

Postal Address

Postal Office

Name	Date of Birth	Relationship to Life Assured
		Self

Name	Date of Birth	Relationship to Life Assured	Mobile No.

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 /-

Payment Mode:

Payment mode for Refund:

Check-Off-Group

Bank

Branch

Accout Name

Account No

Debit Date