The Kenyan Alliance Insurance Company Limited

Dunhill Towers, Waiyaki Way, Westlands

P.O. BOX 30170- 00100 Nairobi, Kenya
Mobile: 0709 334 000 / 0709 234 000
Tel: 0202284000
Email: [email protected]
[email protected]
[email protected]
PRIVATE CAR PROPOSAL FORM
Important Notice: The proposal form must be duly completed and signed by the proposer.
Policy............................................................. Business source......................................................................................
1. Personal Particulars
Name (in full):
ID No: PIN No:

P.O. Box: Town:

Email: Mobile No:
Telephone No:
Nature of Business / Occupation; (to specify)
Period of insurance: D D M M Y Y Y Y to: D D M M Y Y Y Y

2. Name of registered owner of vehicle:

(Provide copy of Logbook)

3. Description of the vehicle (provide a copy of the logbook/importation documents)

i.) Is the vehicle new? Yes No
ii.) Is the vehicle local or imported Yes No
iii.) Is the vehicle? Electric Hybrid Standard

REGISTRATION: MAKE & MODEL OF VEHICLE:

TYPE OF BODY: YEAR OF MANUFACTURE:

CHASSIS NUMBER: ENGINE NUMBER:

ENGINE CAPACITY: SEATING CAPACITY(including driver):

DATE OF PURCHASE: SUM INSURED KSHS (estimate of present value):

CCOLOUR: AMOUNT PAID

NOTE: We will pay on the value of the vehicle at the time of the accident (Pre-accident Value).
4 Please indicate the cover required
(a) Comprehensive (b) Third Party, Fire and Theft (c) Third Party Only
5 (I) State the use of motor vehicle. NOTE: If the vehicle is used for any other purpose or in any other way than as described below, a claim will
not be admissible (Please tick)

i) Used for social, domestic and pleasure purposes

ii) Used for insured profession or occupation

iii) By employees in connection with your own or employers’ business

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 iv)Will passengers be carried for hire or reward or will the vehicle be let on hire? Yes No
(II). Cover Extensions:
(a) Do you require the Windscreen/Window glass to be covered separately by payment of additional premium? If so indicate limit

(b) Entertainment unit and any special feature to be stated in the table below (NOTE: Special features not declared at the time of proposal are
not covered);

SPECIAL FEATURE SERIAL NO. MAKE MODEL VALUE

(c) Own damage excess protector Yes: No:

(d) Political risk and Terrorism Yes: No:
(e) Loss of use: Number of days 10: or 20:
6 Has the vehicle (s) been converted, modified or fitted with any additional equipment above the manufactures set standards in any way
e.g. Spacers Yes No
If yes, please give details.
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Does the vehicle have any defects, unrepaired damages to bodywork or require any mechanical repair? Yes: No:
Where is the vehicle(s) normally kept?
i.) Physical address:
ii.) In a Building? Or in the Open?
7 (a) Is any person who to your knowledge will drive under age of 25? Yes: No:
(b) State your; driving license number:
Original date of issue: D D M M Y Y Y Y

(c) Give the following information in respect of any other person who to your knowledge
will drive.
i. Sole driver
ii. Other authorized drivers:

8 Have you or anyone who to your knowledge will drive ever been convicted of any offence in connection with any Motor Vehicle or any
prosecution pending?
If so give date and nature of penalty. Yes No

DATE NATURE OF PENALTY

9 Have you ever been involved in an accident whilst handling any motor vehicle? (If yes please give details)

YEAR 1 YEAR 2 YEAR 3

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 i.) Name of previous insurer:
ii.) Has any insurer ever declined your proposal or cancelled or refused to renew your policy? Yes: No:
iii.) Has any insurer required an increase in premiums or imposed special conditions? Yes: No:
iv.) Has any insurer required you to contribute to a claim settlement Yes: No:

10 Is a finance company or other party financially interested in the car: Yes: No:
If so, give details.

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11 Is the vehicle fitted with anti-theft device: Yes: No:
Attach certificate of installation:
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(In the absence of anti-theft device, high excess will be imposed in case of claim).
SECTION I - INSURANCE ON THE VEHICLE
What is covered?
1. Loss or damage; We will pay for the loss of or damage to the vehicle(s) or its/their accessories and spare parts while in or on the
vehicle. We may choose to pay cash, repair or replace the vehicle or a part of it or its accessories and spare parts to cover the
amount of the loss or damage. If we settle a claim under this section on total loss basis, the lost or damaged vehicle becomes our
property. The maximum we will pay will be the Market Value of the vehicle immediately before the loss or damage but not more
than the value as shown in the Schedule.
2. Financier's Interest; If the vehicle is under a financing arrangement for which interest, we have noted in this Policy, we will pay
the financier for any total loss or damage. We will then have no further liability to you.

3. Protection, Recovery and Removal after accident; We will also subject to the limits of liability pay the reasonable cost of
protecting, recovering the vehicle and moving it to the nearest repairer or safe place if as a result of any loss or damage insured
under this section the vehicle cannot be driven.

What is not covered under Section I

We will not pay for:
a) consequential loss
b) depreciation, wear and tear, mechanical, electrical or electronic breakdown, failures or breakages.
c) damage to tyres unless damage is caused to other parts of the vehicle at the same time.
d) loss of or damage to the contents being carried in or on the vehicle;
e) damage caused by overloading or strain
f) failure to observe traffic rules
g) driving under the influence of intoxication
h) driving an unroadworthy motor vehicle
i) the excess stated in the schedule.
j) use by any unauthorized driver
k) use of the vehicle outside geographical limit
l) for the carriage of passengers, for hire or reward
m) racing, pace making or trial of speed
n) failure to adhere to traffic Act Cap 403
o) failure to adhere to NTSA regulations

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 SECTION II - LIABILITY TO THIRD PARTIES
1. Indemnity to you or your authorized driver or any person in or getting into or out of the vehicle; We will cover you or any
authorized driver or any person in or getting into or out of the vehicle against legal liability for damages (including the related
costs and expenses) for:
a) Death or bodily injury to any person.
b) Damage to property.
Arising as a result of an accident by or in connection with your vehicle, including while loading and unloading the vehicle as long
as such costs will not exceed the amounts of cover provided for under this Policy.
2. Indemnity to Legal Representatives; Following the death of any person covered under this Policy we will indemnify that
person's legal representatives for liability covered under this Section provided such legal representatives comply with all the
terms and conditions of the Policy
3. Application of Limits of Liability; In the event of an accident involving indemnity under this Section to more than one person
the Limits of Liability will apply to the total amount of indemnity to all persons indemnified and such indemnity will apply as per
your priority.
4. Representation and Defence; We may at our own option:
(a) Arrange for representation at any inquest or inquiry the subject matter of which may give rise to indemnity under this
Section,
(b) Undertake the defence of proceedings in any Court of Law in respect of any act or alleged offence causing or relating to any
event which may be the subject of indemnity under this Section.
What is not covered under Section II
We will not pay for:
(a) For death of or bodily injury to any person in your employment arising out of and in the course of such employment.
(b) For damage to property held in your trust, custody or control or belonging to you or any member of your household.
(c) For damage to property held in trust, custody or control or belonging to any other person claiming to be indemnified under
subsection 1.
(d) The first amount as shown in the schedule of each claim (applicable excess).

These general exceptions apply to all sections of this policy.

We will not be liable in respect of:
1. Any accident, loss, damage or liability caused, sustained or incurred;
(a) Outside the Territorial Limits, or
(b) While on your order or with your permission or to your knowledge any vehicle in respect of which indemnity is provided by this
Policy is being used contrary to the Limitations as to Use clause.
2. Any accident, injury, loss, damage or liability if the vehicle is carrying more than its authorised capacity.
3. Any liability which attaches by virtue of an agreement but which would not have attached in the absence of such agreement
The above is a summary of the exclusions of the policy and is not necessarily complete.
CLAIMS
(a) You must report to the police within twelve hours, for any accident, injury or theft of your vehicle. Ensure you do not leave the
scene of the accident until police arrive and take your statement
(b) You must report to us any accident, injury, loss or damage involving your vehicle(s) within twelve hours. Failure to report within
the timelines required will result to non-payment of a claim.
(c) If the vehicle(s) is/are lost or damaged as a result of theft, attempted theft or malicious damage, you must within twelve hours
make a report to the police and obtain a police report. Further for any accident or injury a police abstract must be obtained within
twelve hours.
(d) You must also inform us within twelve hours you become aware of any current or future prosecution or proceedings in connection
with any event for which there may be any liability under this policy.
(e) Any correspondence relating to any incident should be sent to us within twelve hours and unanswered. We will be entitled to
take over and carry out in your name the defense or settlement of any claim. We shall also prosecute in your name to recover any
amounts we have paid.
(f) When you make a claim, we will be entitled to instruct and give information relating to the claim to other people such as lawyers,
investigators, loss assessors, garages and we expect you to give them all the necessary co-operation.

IMPORTANT CONDITIONS
i) Failure to disclose all material facts in the Proposal Form may invalidate the cover under your Policy and it is an offence
to make false statements or withhold any material Information (whether you consider material or not) for the purpose
of obtaining a certificate of Motor Insurance
ii) Vehicle must be insured for full market value
iii) Do not admit liability in case of an accident, we shall act on your behalf
iv) Report incidents to us immediately via our rescue lines 0708 334 000, 0709 234 000 and 0709 334 000

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 DECLARATION
a) The above statements are true.
b) All material particulars affecting the assessment of the risk have been disclosed.
c) The vehicle(s) is/are in a sound roadworthy condition i.e., the tyres are of good tread depth, brakes in working condition, vehicle is
mechanically sound and I undertake to service my motor vehicle as per stipulated specifications of the manufacturer
I/We warrant that the above statements are true, and that I/We have not withheld or concealed any material particulars affecting the
assessment of the risk and that I/We agree that this proposal shall be basis of the contract between the Client and THE KENYAN
ALLIANCE INSURANCE COMPANY LIMITED.
I/We further agree that if this proposal in any particular is filled by any other person, such person shall be deemed My/Our agent and
not the agent of the company. I/We further declare that I/We have read and understood all particulars entered herein and I/We have
signed this after verifying the same to be true and complete in all respects.

Date: D D M M Y Y Y Y Policy holder's Signature: .................................................

Name: .................................................

IMPORTANT NOTE: We shall use the email address you have provided herein to dispatch all documents subject of this policy,
and shall presume you have received them on the day we dispatch. No liability shall attach until full premium is received.

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