Tontozo

Section 1 - Policyholder Details

(Always complete this section. This individual is the Owner and the Principal Life Assured under the Policy terms and conditions. This Individual is entitled to receive all Benefits ascribed to this Policy)

Surname :

First Name :

NRC# :

Email Address :

Confirm NRC# :

Date Of Birth :

Gender :

Male Female

Mobile :

Telephone :

Postal Address :

(Note : Add Postal Code if you have.)

Section 2 - Beneficiary Details

(In the event of the Policyholder becoming deceased, these are persons nominated by the Policyholder to recieve payment of benefits. Please ensure that %share adds up to 100% across all beneficiaries)

First Name	Surname	Contact Number	Relationship

Section 3 - Dependant Details

(Complete if family and parents in law or extended family benefit is selected. Please note that more than 6 children can be listed, but claims will be paid for a maximum of 6 children.)

First Name	Surname	Date Of Birth	Age	Relationship	Gender
					Male Female

Section 4 - Benefit Details

(Always complete this section.)

Plain Type (Please Indicate With A () Lives Covered And Benefit Level Selected)

BENEFIT OPTION UNDER 65

BENEFIT OPTION ABOVE 65 (SENIOR)

Main Benefit (Please Indicate With A () Lives Covered And Benefit Level Selected)

	Main Member / Individual Policy					Family (Main Member, Spouse, Up to six Children)
Benefit Amount (K)	2,500	5,000	10,000	15,000	20,000	2,500	5,000	10,000	15,000	20,000
Cost for Benefit Option Under 65 (K)	17	25	41	56	72	24	39	69	99	129
Cost for Benefit Option Above 65 (K)	38	66	122	178	234	42	75	141	206	272
Benefit Selection ()

Main Benefit Cost (K) :

TOP UP CASH BENEFIT OPTION (Please Indicate With A () Lives Covered And Benefit Level Selected)

	Main Member			Main Member and Spouse
Benefit Amount (K)	1,500	2,500	5,000	1,500	2,500	5,000
Cost for Benefit Option Under 65 (K)	5	8	16	10	16	32
Cost for Benefit Option Above 65 (K)	17	29	57	34	58	114
Benefit Selection ()

Top Up Cash Cost (K) :

TOMBSTONE BENEFIT (Please Indicate With A () Lives Covered And Benefit Level Selected)

	Main Member				Main Member and Spouse
Benefit Amount (K)	5,000	10,000	15,000	20,000	5,000	10,000	15,000	20,000
Cost for Benefit Option Under 65 (K)	16	32	47	63	32	64	94	126
Cost for Benefit Option Above 65 (K)	57	113	169	225	114	226	338	450
Benefit Selection ()

Tombstone Cost (K) :

PARENTS AND PARENTS IN LAW BENEFIT (Please Indicate With A () Lives Covered And Benefit Level Selected)

	Parents and Parents In law Benefit
Benefit Amount (K)	2,500	5,000	10,000	15,000	20,000
Cost Per Person Benefit(K)	24	48	96	144	186
Benefit Selection ()

Parents Cost (K) :

No of parents(max 4 people) :

EXTENDED FAMILY MEMBER BENEFIT (Please Indicate With A () Lives Covered And Benefit Level Selected)

	Extended Family Member Benefit
Benefit Amount (K)	2,500	5,000	10,000
Cost Per Person Benefit(K)	15	30	60
Benefit Selection ()

Extended family Cost (K) :

No. of extended members(max 6 people) :

Annual Benefit Increase (ABI) for Tontozo Plan

TOTAL COST PAYABLE FOR TONTOZO PLAN (K) :

(Across All Benefits Selected)

Section 5 - Payment Details

(Always complete this section for new applications, and complete for amendment if relevant. The Policyholder and cost payer must be the same person. Please indicate with a (✓) the selected payment method)

Payment Method

Debit Order

EFTS

DEBIT ORDER PAYMENT DETAILS (COMPLETE IF DEBIT ORDER PAYMENT IS SELECTED)

(Please attach a copy of the latest bank statement – must not be older than 3 months, or confirmation of account details from the Policyholder’s Bank on the Bank’s letterhead.)

Name Of Account Holder :

Name Of Bank :

Branch Name :

Branch Code :

Account Number :

I, the undersigned authorize Liberty Life Insurance to, in terms of the agreement, deduct the cost for the amount as specified in this form, from this account, including any applicable cost increases I have selected or any increases that Liberty may apply as agreed with me, until the due cost on this policy is paid.

Account Holder's full name:

Debit Order Date :

Account holder’s signature :

(Not happy with signature? Press clear and sign again)

Name Of Account Holder :

EFTSAccountHolderName

Name Of Bank :

EFTSBankName

Branch Name :

EFTSBranchName

City :

EFTSCityName

Swift :

EFTSSwiftCode

Branch Code :

EFTSBranchCode

Account Number :

EFTSAccountNo

Section 6 - For Agents Only

By submitting an application, I declare that I have explained all material terms and conditions of the policy to the policyholder. I also confirm that I have verified the identity of the policyholder in accordance with the regulations set out in the related legislation, regulations or guidelines. I have loaded copies of all required documents on the Liberty system.

Agent/Agency name :

City/Town :

Agent full name :

Agent signature :

(Not happy with signature? Press clear and sign again)

Section 7 - Declaration By the Policyholder

(Always Complete this section)
(Complete if family and parents in law or extended family benefit is selected. Please note that more than 6 children can be listed, but liberty life will pay for a maximum of 6 children.)

This declaration contains guarantess and undertakings that I, as the policyholder and the Principal Life Assured agree to.

I confirm that I understand the product and policy :

Check all Declaration

I confirm that I understand the nature of the product and that the authorized representative has explained the product rules, Terms and conditions, and relevant marketing material.

I confirm that I terms and conditions have been explained and issued to me by the authorized representative.

I guarantee that i am giving information correctly :

All information given to the Underwriter in respect of any transaction is true and accurate and can be relied on for contracting.

Where any material information is not fully disclosed, or is found to be untrue, the Underwriter may decide to cancel the policy and/or not pay any claim or benefits.

I guarantee to keep my details up to date:

I undertake to keep the Underwriter informed of any changes to the information supplied on this application, which includes but is not limited to my contact details to enable the Underwriter to communicate with me.

I authorise the Underwriter and the authorized representative:

To collect and process certain personal and financial information from me if relevant to my policy.

I authorize the Underwriter to collect and share information.

I accept that with this authorization I am limiting my right to privacy. However to assess the insurance risk, I irreversibly authorize the Underwriter to :

a) Obtain from any person, whom I hereby permit and request to give any information which the Underwriter needs, and

b) Share with other insurers that information and any information in this application or any related source at any time, in a form approved by the Underwriter or the Regulator.

I, the undersigned, confirm that the information supplied on this form is to the best of my knowledge true and correct. I further acknowledge that the Underwriter and the authorized representatives accept no responsibility or liability for the accuracy of the information provided by myself.

Policy holder name and surname :

I hereby confirm this application through upload of my National Registration Card (NRC)

Front Side NRC Photo : Front Side NRC Photo:

Applicant Photo : Applicant Photo:

Captcha :

Enter the text you see above:

Back Side NRC Photo : Back Side NRC Photo:

Signature :

(Not happy with signature? Press clear and sign again)

Date : 04/24/2024

Apply Now

Tontozo Application Form

Section 1 - Policyholder Details

Section 2 - Beneficiary Details

Section 3 - Dependant Details

Section 4 - Benefit Details

Plain Type (Please Indicate With A () Lives Covered And Benefit Level Selected)

Main Benefit (Please Indicate With A () Lives Covered And Benefit Level Selected)

Main Benefit Cost (K) :

TOP UP CASH BENEFIT OPTION (Please Indicate With A () Lives Covered And Benefit Level Selected)

Top Up Cash Cost (K) :

TOMBSTONE BENEFIT (Please Indicate With A () Lives Covered And Benefit Level Selected)

Tombstone Cost (K) :

PARENTS AND PARENTS IN LAW BENEFIT (Please Indicate With A () Lives Covered And Benefit Level Selected)

Parents Cost (K) :

No of parents(max 4 people) :

EXTENDED FAMILY MEMBER BENEFIT (Please Indicate With A () Lives Covered And Benefit Level Selected)

Extended family Cost (K) :

No. of extended members(max 6 people) :

TOTAL COST PAYABLE FOR TONTOZO PLAN (K) :

Section 5 - Payment Details

Payment Method

DEBIT ORDER PAYMENT DETAILS (COMPLETE IF DEBIT ORDER PAYMENT IS SELECTED)

Section 6 - For Agents Only

Section 7 - Declaration By the Policyholder