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: life@icealion.com • www.icealion.com

1. Name, Designation, Residence and address of the Person Name of Purchaser/Scheme: ___________________________
or Persons purchasing the annuity.
__________________________________________________
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 First Name Middle Name

Date of Birth D D M M Y Y Y Y
ID No. PIN No. Tel
(Please attach a certified copy) (Please attach a certified copy)

P.O. Box Code Town

Sex 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 Land Reg. No. (LR No.)

Estate Name House No. Town/Area

4. Amount of Purchase Money - (Purchase Price) _____________________ Installments of Annuity to be:

Amount of Annuity to be purchased: (Annual Pension) _____________________ Yearly Quarterly

(Monthly Pension) _____________________

Half Yearly Monthly

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: _____________________