Individual Life Proposal Form

  • Proposer Details
  • Life to be Assured
  • Beneficiary Details
  • Plan Information
  • Health Questions
  • Supplementary Questions
  • Family History
  • Insurance History
  • Authority To Obtain Info

Personal Details

Contact Details

P.O. Box

Personal Details

Contact Details

P.O. Box

Personal Details

Beneficiary 1

Plan Information Details

Generate Plan Information on the basis of:
Rider Name Apply Sum Assured Premium Type
S.No Year Amount

Total Premium: KES 0

Health Questions

Q. Are you now, in all respects, not in good health?

Q. Have you consulted any doctor as an inpatient or outpatient in the last 3 years?

Q. Are you now pregnant? If Yes, how many weeks?

Q. Have you had an X-Ray, electrocardiogram or undertaken any medical tests within the past six (6) months?

Q. Are you currently on any medication?

Q. Have you ever had a serious injury that required critical care and or hospitalization?

Q. Have you suffered from, had symptoms of or been told by a medical practitioner that you had: (Tick appropriate item and give details where applicable)

Q. Dizziness, fainting, convulsions, epilepsy, paralysis, stroke or severe headaches?

Q. Depression, anxiety, Alzheimer's disease, mental or nervous disorder?

Q. Shortness of breath, bronchitis, emphysema, asthma, pleurisy, pneumonia, tuberculosis or persistent cough ?

Q. Chest pain, angina, palpitations, irregular heart beat, high blood pressure, heart attack, congestive heart failure or coronary artery disease ?

Q. Heart murmur, heart valve disorder, oedema or disorder of the heart or blood vessels?

Q. Ulcer, intestinal bleeding, colitis, ulcerative colitis, Crohn's disease, jaundice, hernia, diarrhoea, hepatitis or any disorder of the stomach, intestines, spleen, liver, or rectum ?

Q. Diabetes, high blood sugar or sugar in your urine?

Q. Blood or protein in your urine, any disorder of the kidneys, bladder, prostate or urinary system?

Q. Malaria, Black water Fever, or any other tropical diseases?

Q. Thyroid, thymus, pituitary or lymph gland disorder?

Q. Venereal disease or any disorder of the reproductive system?

Q. Cancer, sarcoidosis, tumour or any abnormal growth?

Q. Back pain, arthritis, muscular dystrophy or any disorder of the muscles, bones or joints?

Q. Multiple Sclerosis, Parkinson's disease or any disorder of the brain or spinal cord?

Q. Haemophilia, Sickle Cell anaemia, anaemia or any disorder of the blood?

Q. Any other condition or disease not mentioned above?

Q. Have you ever had or been advised to have a blood test for AIDS, AIDS related or immunological condition?

Q. Have you ever been refused as a blood donor?

Q. Have you ever received a blood transfusion within the last 5 years?

Supplementary Question Details

Q. Have you lost/gained weight in the last two months?

Q. Have you any intention of engaging in any unusually hazardous circumstances which might affect this assurance(for example dangerous sports, student pilot, service in the armed forces, motor sports, aviation other than a fare paying passenger on a scheduled airline, water skiing, underwater diving, para - chuting gliding and mountain climbing or any other hazardous occupation, sport or pastime) ?

Q. Do you use intoxicating drink, tobacco or nicotine products or habit-forming drugs?

Q. Have you ever been convicted of a felony or misdemeanour within the last five (5) years or have any charges currently pending

Family Details

Father Details

Mother Details

Brother/Sister Details

Insurance Details

Q. Have you ever applied for life insurance?

Q. Has a proposal on your life ever been declined, postponed, withdrawn or accepted on special terms?

Authority To Obtain Details

Give the name and address of your personal doctor or medical facility where your medical records may be obtained:

I accept that I am curtailing my right of privacy, to facilitate the assessment of the risks, and the consideration of any benefits under a policy related to this or any other application for insurance made by me, or in respect of me as life to be assured and hence irrevocably authorise that:

  • any institution wherther insurance company, Association of Kenya Insurers Life Registry or any medical practitioner, hospital, clinic, medical facility; having any records pertaining to me or my health, to provide KOLAL or its reinsurers with any information sought, at any time(even after death)
  • information obtained with this authorisation may only be used as lawfully required, to determine insurability or as I may accept.

NOTE: Information regarding your insurability will be treated confidentially. We may however, make required reports to the Association of Kenya Insurers Life Registry and may also release information to other insurance companies to whom you apply for insurance or to whom a benefit claim may be reported.