PROPOSAL FOR THE PURCHASE OF AN ANNUITY ICEA LION Centre, Chiromo Road • P.O.Box 46143 - 00100 GPO Nairobi, Kenya Tel: +254 (20) 2750 000/ 2221 652/ 719 071 000 • Fax: +254 (20) 224 4258, Email:
[email protected] • www.icealion.com
1. Name, Designation, Residence and address of the Person or Persons purchasing the annuity.
Name of Purchaser/Scheme: ___________________________
__________________________________________________ Note – The person here named as purchaser will be held to be the contracting party and will retain Complete control of Designation ________________________________________ the annuity payments. P.O Box Code _______________________________________ Town _____________________________________________
2. Description of annuity:
Type of Annuity,
__________________________________________________
Guarantee Period/Term
__________________________________________________
Escalation Rate (%)
__________________________________________________
3. Name, Designation and residence of the Person or persons upon whose lifetime the Annuity is to depend. Note - it is necessary to present satisfactory evidence of age of the Principal, and in the case of married woman or widow a Certificate of Marriage. Attach copies of documents. Surname: Prof/Dr/Mr./Mrs Last Name Date of Birth
D D
M M
First Name
Middle Name
Y Y Y Y
ID No.
PIN No. (Please attach a certified copy)
P.O. Box Sex
Tel (Please attach a certified copy)
Code
Town
Marital Status
Email Address
RESIDENTIAL AND UTILITY DECLARATION Kindly attach your latest utility bills (Electricity, Water or Telephone) or fill the section below: Residence Area Estate Name
Land Reg. No. (LR No.) House No.
(Purchase Price)
Town/Area
_____________________
Installments of Annuity to be:
Amount of Annuity to be purchased: (Annual Pension)
_____________________
Yearly
Quarterly
(Monthly Pension)
_____________________
Half Yearly
Monthly
4. Amount of Purchase Money -
5. Date upon which the Installments of Annuity are to commence. (Commencement date must be the first day of a month – dd/mmm/yyyy)
__________________________________________________
MANDATE TO ICEA LION LIFE ASSURANCE COMPANY LIMITED I hereby authorize the ICEA LION LIFE ASSURANCE COMPANY LIMITED until further notice to pay as and when they become due all sums payable under the Annuity now applied for on the life of _____________________________________________ to: A/C Name ___________________________________________ Bank _____________________________________________ Branch ___________________________________________ A/C. No. _____________________________________________
Signature of Annuitant _____________________________________________ Date: _________________________________
INTERMEDIARY DETAILS Name of Intermediary ________________________________________ Intermediary Code ____________________________ Branch Code _____________ Email ____________________________ Stamp P.O. Box ____________ Code ___________ Town ______________________ Tel _________________________________
BENEFICIARIES Full Names
Date of Birth
ID/Passport No.
Telephone No.
Postal Address
Proportion (%)
Signature of Annuitant ___________________________________________________ Date ___________________________ DECLARATION We, ____________________________________________________________________________ do hereby declare that the above is a true statement of the particulars therein required to be set forth, and we do hereby agree that this Declaration shall be the basis of the contract between us and the ICEA LION LIFE ASSURANCE COMPANY LIMITED. Dated at ___________________ the ______________ day of ______________ Two Thousand and _______________________ 1st Trustee: Name ____________________________________________________ Stamp Signature: ____________________________ Date: _____________________
2nd Trustee: Name ____________________________________________________ Stamp Signature: ____________________________ Date: _____________________
