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Suluhu Application Form

The document is an application form for the Suluhu Mkononi Plan offered by Pioneer Assurance Company Limited in Nairobi, Kenya. It collects personal, employment, and beneficiary details, as well as payment preferences and health information from the applicant. The applicant must declare the accuracy of the information provided and consent to electronic delivery of the policy document.

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64 views1 page

Suluhu Application Form

The document is an application form for the Suluhu Mkononi Plan offered by Pioneer Assurance Company Limited in Nairobi, Kenya. It collects personal, employment, and beneficiary details, as well as payment preferences and health information from the applicant. The applicant must declare the accuracy of the information provided and consent to electronic delivery of the policy document.

Uploaded by

Warriors Cyber
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PIONEER ASSURANCE COMPANY LIMITED, MOI AVENUE. P.O.

Box 20333-00200, Nairobi, Kenya


Email: [email protected] ||www.pioneerassurance.co.ke Tel: 020-7220000

SULUHU MKONONI PLAN


SULUHU MKONONI OWNER DETAILS
NAME:

DATE OF BIRTH: GENDER: MARITAL STATUS: PHONE:

EMAIL ADDRESS:

ID/PASSPORT NUMBER: KRA PIN NUMBER: PHYSICAL ADDRESS:

EMPLOYMENT INFORMATION
STATE YOUR OCCUPATION:

EMPLOYER’S NAME

BENEFICIARY DETAILS
NAME RELATIONSHIP % SHARE CONTACT
DATE OF BIRTH

SULUHU MKONONI PLAN DETAILS


START DATE PERIOD IN YEARS END DATE Preferred date of first installment

MODE OF PAYMENT : DAILY MONTHLY QUARTERLY SEMI ANNUAL ANNUAL LUMPSUM

CONTRIBUTION AMOUNT:
METHOD OF PAYMENT : CASH MPESA CHECK-OFF BANK STANDING ORDER

HEALTH QUESTIONS
Do you have any medical condition? (YES/ NO)

If yes, kindly specify the condition, duration, and treatment below.

DECLARATION AND AUTHORIZATION

I the Suluhu Mkononi owner declare and agree that;

 This application is hereby made to Pioneer Assurance according to the company’s terms and conditions.
 The information provided in this application is true, correct and accurate and that the money used for this policy does not arise out of
the proceeds of any money-laundering or other illegal activities.
 Pioneer Assurance reserves the right to verify all information provided herein.
 The information provided in this application and in any other documentation submitted in connection to this application forms the
basis of this policy.
 I consent to have my policy document delivered to me through electronic email indicated in this proposal. I also understand that my policy document
will be considered delivered once dispatched to this email.

CUSTOMER SIGNATURE: DATE:

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