PROPOSAL FOR THE PURCHASE

OF AN ANNUITY
ICEA LION Centre, Riverside Park, Chiromo Road, Westlands • P.O. Box 46143 - 00100, Nairobi, Kenya • Tel: 020 2750 000
• Tel: 0719 071000 • Fax: +254 (20) 2244 258 • Email: life@icealion.com • Website: www.icealion.com

1. Name, Designation, Residence and address of the Person 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 the annuity payments.
Name of Purchaser/Scheme: ____________________________
___________________________________________________
Designation _________________________________________
P.O. Box ________________ Code ____________________

Town ______________________________________________

2. Description of annuity: Type of Annuity, ___________________________________________________

Guarantee Period/Term ___________________________________________________

Escalation Rate (%) ___________________________________________________

Deferred Period (if applicable) ___________________________________________________

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
Day/Month/Year

ID No. PIN No. Tel. No.

(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)* ____________________ Instalments of Annuity to be:

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

Half Yearly Monthly

(Gross Monthly Pension) ____________________
5. Date upon which the Instalments of Annuity are to commence.
(Commencement date must be the first day of a month – dd/mmm/yyyy)
*Attach Benefit Computation Worksheet.
 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. _____________________________________________

whose receipt shall be a full and sufficient discharge thereof.

Signature of Annuitant ________________________________________ Date: _________________________________

(Attach copy of front side of ATM card)

INTERMEDIARY DETAILS

Name of Intermediary _______________________________________ Intermediary Code ________________________

Branch Code _____________ Email ____________________________ Stamp

P.O. Box ____________ Code ___________ Town ______________________

Tel _________________________________

BENEFICIARIES
BENEFICIARIES
National ID/ Proportion
Full Names Relationship Date of Birth Telephone No. Postal Address
Passport No. (%)

Signature of Annuitant ________________________________________________ Date _______________________

DECLARATION BY ANNUITANT
1. I declare that all the answers in this proposal form are in every respect true, correct and complete and I agree that the Annuity
Contract between me and ICEA LION LIFE ASSURANCE COMPANY LIMITED shall be based on this proposal and
declaration.
2. I undertake to provide ICEA LION LIFE ASSURANCE COMPANY LIMITED with any information required to administer
my Annuity Contract.
3. I understand that the Annuity Contract is subject to physical completion of a certificate of existence in the presence of an eligible
verifier at intervals determined by ICEA LION LIFE ASSURANCE COMPANY LIMITED from time to time.
4. I understand that ICEA LION LIFE ASSURANCE COMPANY LIMITED is required to deduct tax from any payments to me.

Signature of Annuitant ________________________________________________ Date _______________________

TRUSTEE DECLARATION (for transfers from an Occupational Retirement Benefit Scheme only).

I/We agree to the setting up of this policy in the name of the Annuitant.

1st Trustee:

Name _________________________________________________________

Signature: ____________________________ Date: _____________________

*Affix the official stamp of the Fund.

2nd Trustee:

Name _________________________________________________________

Signature: ____________________________ Date: _____________________