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BRITAM Annuity Application Form New

This document is an application for an annuity policy from Britam Life Assurance Company. It collects personal details of the applicant and spouse if applying for a joint life annuity. It requests contact and bank details as well as annuity details including payment frequency, guarantee period, escalation rate, and optional last expense benefit. The applicant declares the information is true and complete and agrees the application will form the contract basis between them and the company. Space is provided for signatures of applicant, intermediary, and official use.

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kevin muchunga
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683 views1 page

BRITAM Annuity Application Form New

This document is an application for an annuity policy from Britam Life Assurance Company. It collects personal details of the applicant and spouse if applying for a joint life annuity. It requests contact and bank details as well as annuity details including payment frequency, guarantee period, escalation rate, and optional last expense benefit. The applicant declares the information is true and complete and agrees the application will form the contract basis between them and the company. Space is provided for signatures of applicant, intermediary, and official use.

Uploaded by

kevin muchunga
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

BRITAM LIFE ASSURANCE COMPANY

APPLICATION FOR ANNUITY POLICY


Quotation Number
APPLICANT DETAILS
NAME OF APPLICANT
NAME OF SPOUSE (for Joint Life Annuity)
APPLICANT'S ID NUMBER

APPLICANT'S PIN NUMBER


PURCHASE PRICE

OCCUPATION SOURCE OF FUNDS


Applicant's Date of Birth Gender Spouse's Date of Birth
D D M M Y Y Y Y D D M M Y Y Y Y

CONTACT DETAILS
MOBILE NUMBER EMAIL
P.O BOX POSTAL CODE TOWN
PHYSICAL ADDRESS/RESIDENCE
ANNUITY DETAILS
SPOUSE REVERSION RATE % GUARANTEE PERIOD Years ESCALATION RATE %

PAYMENT FREQUENCY MONTHLY QUARTERLY SEMI ANNUALLY ANNUALLY

LAST EXPENSE BENEFIT DETAILS (Optional)


Would you like to purchase a last expense (funeral) cover? YES NO

Sum Assured
BANK DETAILS
ACCOUNT NAME
NAME OF BANK BRANCH
ACCOUNT NUMBER
BENEFICIARY NOMINATION
FULL NAME RELATIONSHIP AGE SHARE (%) TELEPHONE/ADDRESS

Guardian for Beneficiaries under the age of 18 :


Name Relationship to Beneficiary Address & Telephone Number

DECLARATION
I declare that the above statements are to my knowledge and belief true and complete, and agree that this application
form shall form the basis of the contract between me and the Company.
Applicant's Signature : Date :
Name of Intermediary : Signature of Intermediary :

Intermediary Debit Number : Branch :


FOR OFFICIAL USE ONLY

Commencement Date D D M M Y Y Y Y Gross Annuity (Kshs)


Funeral Plan Quotation Number Funeral Plan Single Premium

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