Proposal Number
LAST EXPENSE COVER
PERSONAL DETAILS OF POLICY OWNER
First Name(s) Surname
ID Number Passport Marital Status Title
Date of Birth (DDMMYYYY) Nationality Gender
Occupation
Citizenship 1 Citizenship 2 Citizenship 3
Residency 1 Residency 2 Residency 3
Tax Identification Number (TIN) (For US citizens only) Pin Number
EMPLOYMENT DETAILS
Employed? Y/N Employer
Employee Number Employment Terms: Temporary Permanent Contract
BUSINESS DETAILS
Business Name
Nature of Business Role of proposer in business
CONTACT DETAILS
Cell (Pre-fix for other countries) Work Phone Home Phone
Wireless Email
P. O. Box Postal Code Postal Town
Physical Address Street/Location Town County
Building/Village
How would you like us to communicate with you? Post Mail Fax SMS
USA PHYSICAL ADDRESS (For USA citizen only)
P. O. Box Town / City
Region / State ZIP CODE
SPOUSES DETAILS
First Name(s) Surname
Date of Birth Gender M Y Occupation
ID Number / Passport Marital Status Title Cell (Pre-fix for other countries)
CHILDRENS’ DETAILS
First Names Surname Date of Birth Relationship Student? ID Number Birth ceritificate
Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority
[Link]/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 bancassurance@[Link] Paybill No.: 522666 Paybill No.: 522666
Proposal Number
PARENTS / PARENTS IN-LAWS’ DETAILS
First Names Surname Date of Birth Relationship ID Number
EXTENDED FAMILY DETAILS
First Names Surname Date of Birth Relationship ID Number
BENEFICIARY/NOMINEE OF THE POLICY (Above 18 Years)
First Name(s) Surname
ID Number Date of Birth (DDMMYYYY) Gender
Relationship to policyholder Cell (Pre-fix for other countries) Benefit Share %
PAYMENT METHOD
Banker's Order Direct Debit Check Off Cheque (Non Monthly Cases Only) FOSA
PREMIUM PAYMENT FREQUENCY
Monthly Quarterly Semi Annually Semi Annually
PLAN SELECTION
Bronze Silver No. Premium Total Premium
Policy Holder (Maximum entry age 65 years)
Spouse (Maximum entry age 65 years)
Gold Platinum
Children (Maximum entry age 18 years)
Parents (Up to 85 years)
Diamond
Extended Family (Up to 85 years)
Sub Total
0'25% Policy Holder
Compensation Levy (PHCL)
Total Premium Payable
CONFIRMATION
Kindly confirm the following: I confirm to the best of my ability that all members mentioned in this policy are in good health. Y/N
If not, kindly provide details.
I declare that the answers to the above questions and statements, whether in my own handwriting or not, are true and complete.
I understand that the answers to the above questions and statements and any documents required shall be the basis of the contract.
Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority
[Link]/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 bancassurance@[Link] Paybill No.: 522666 Paybill No.: 522666
Proposal Number
DATA PRIVACY NOTICE
Consent & Declaration to personal/corporate information/data
I/We agree that Sanlam Life Insurance Limited (“Sanlam”) and KCB Group (“KCB”) will:
(i) collect, and process my/our personal data for purposes that are relevant to my/our policy and as permitted by law. The collection and
processing of my/our personal data is in accordance with the privacy statement on Sanlam’s website
([Link] and KCB’s website
([Link] );
(ii) ensure that it fulfills my/our rights as a data subject, which include my right to:
(a) be informed of the use to which my/our personal data is to be put.
(b) access my/our personal data in custody of Sanlam.
(c) object to the processing of all or part of my/our personal data.
(d) correction of false or misleading data about me/ourselves; and
(e) deletion of false or misleading data about me/ourselves
(iii) transfer my/our personal data to your reinsurers, other insurance companies, regulatory agencies, and affiliated
companies/parties for the purposes of my/our policy and as permitted by law.
(iv) transfer my/our personal data to Sanlam’s contracted third parties for purposes of contact you via email/phone
call/SMS/post regarding my/our policy; and
(v) ensure that there are technical and organisational security measures taken to ensure the integrity and confidentiality of the data
I/We understand the collection and processing of my/our personal data is mandatory for purposes that are relevant to my/our policy and as
by law. If I/We do not provide all the requisite personal data, Sanlam will be unable to fulfill its obligations to me/ourselves under the policy
For any inquiries relating to the processing of your personal data by Sanlam, please feel free to reach out to us through
customerservice@[Link] or dpo@[Link]
Client Name/Scheme Name Policy Number
ID Number Designation/Position
Cell No/Landline Email Address
Date Sign
Stamp (For Corporates)
IMPORTANT NOTICE TO APPLICANT
No agent or staff of Sanlam Life is authorised to receive cash on behalf of the institution. All premium payments by cash must be banked
into the company’s account provided for this purpose or paid into the company’s M-Pesa pay bill number 120120. Sanlam Life shall not
be liable for any cash given to a staff or agent. Upon acceptance of this application, Sanlam Life Insurance Limited shall deliver your
policy document by electronic means only through the email address you have provided and also where you have signed up to use the
Sanlam online customer portal, through this portal. No physical policy shall be delivered for this application.
I acknowledge that I have read and understood these declarations.
Client Signature Date
Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority
[Link]/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 bancassurance@[Link] Paybill No.: 522666 Paybill No.: 522666
Proposal Number
AGENT DECLARATION
I hereby declare that I have explained the contract and the meaning and implications of replacements to the life to be assured and that
I am fully aware of the possible detrimental consequences of the replacement of any insurance contract. I declare that all the
information contained in this proposal was obtained from the life to be assured and was completed in his/her presence.
Agent's Code ID Number Signature
Channel of Distribution: Sanlam Life KBIL NBIL
Name of Agent Surname of Agent Date
Name of Sales Manager Surname of Agent Date
Branch
Client Signature Date
Disclaimer
1. This Application is subject to Sanlam Life's Approval and acceptance procedure.
2. Sanlam Life is regulated by the Insurance Regulatory Authority
Sanlam Life Insurance Limited and KCB Bancassurance Intermediary Limited are Regulated by the Insurance Regulatory Authority
[Link]/insurance SMS: 22522 0711 087 000 / 0732 187 000 /0727444000 bancassurance@[Link] Paybill No.: 522666 Paybill No.: 522666
