Protect Your Employees in Minutes

Answer a few questions about your business and employees, and we'll prepare your WIBA Insurance proposal for a Geminia advisor to quote.

About you

Proposer's details

Part 1 of the official Geminia WIBA Insurance proposal form — indemnity to the employer under the Work Injury Benefits Act, 2007.

Name in full *

Please enter the proposer's name.

KRA PIN number (optional)

Email address *

Enter a valid email address.

Postal address (optional)

Postal code (optional)

Town (optional)

Telephone number(s) (optional)

Fax number (optional)

Physical address / location of premises *

Please enter the location of the premises.

Nature of business / occupation (optional)

Period of insurance — From (optional)

Period of insurance — To (optional)

Please have your Certificate of Incorporation and KRA PIN Certificate ready — your advisor will request copies.

Quick check

Prior insurance & employee health

A few background questions.

Are you at present insured, or have you ever proposed for, a workmen's compensation policy or work injury benefits policy? *

No Yes

Please let us know.

Have such proposals or renewals ever been declined or withdrawn? *

No Yes

Please let us know.

If yes, give details

Have increased rates been required for such proposals or renewals? *

No Yes

Please let us know.

Do you have any employee with a pre-existing medical condition? *

No Yes

Please let us know.

If yes, please give details

Your employees

Employee schedule

Employees being workers as defined by Section 5 of the Work Injury Benefits Act, 2007. Maximum age allowed in the policy is 65 years.

Employee group 1

Names / number of employees *

Please describe this employee group.

Description of occupation

Estimated annual salary/wages

KES

Employee group 2 (optional)

Names / number of employees

Description of occupation

Estimated annual salary/wages

KES

Employee group 3 (optional)

Names / number of employees

Description of occupation

Estimated annual salary/wages

KES

More occupation groups? List the rest with your advisor on a supplementary sheet.

Do the above salaries include constant allowances (e.g. housing, commuters)? *

Yes No

Please let us know.

It's a condition of this policy that estimated annual wages, salaries and earnings are certified annually by your auditors within 3 months of the expiry date of the period of insurance.

History

Claims history

Your accident/claims record for recent years. Leave blank if not applicable.

Year 1 (most recent, optional)

Year

Wages, salaries and other earnings

KES

Number of accidents (whether or not involving claims)

Claims settled — number

Claims settled — cost

KES

Claims outstanding — number

Claims outstanding — cost

KES

Year 2 (optional)

Year

Wages, salaries and other earnings

KES

Number of accidents

Claims settled — number

Claims settled — cost

KES

Claims outstanding — number

Claims outstanding — cost

KES

More years of history? Share the rest with your advisor.

Almost done

Declaration

Confirm the declaration to complete your proposal.

Name of person completing this form *

Please enter a name.

Designation (optional)

Your signature *

Sign here

Draw with your mouse, or your finger on a touchscreen. This is embedded into your proposal PDF.

Please sign before submitting.

By signing and submitting, you declare that the statements set forth herein are true and complete, and that no material facts have been missed or misrepresented.

Review

Does everything look right?

Take a quick look before we prepare your quotation.

Thank You! 🎉

We've received your request. A Geminia Insurance advisor will prepare your quotation and contact you shortly.

If we need any additional information, we'll reach out to you.

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Protect Your Employees in Minutes

Proposer's details

A few questions about your premises

Prior insurance & employee health

Employee schedule

Claims history

Declaration

Does everything look right?

Thank You! 🎉

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