SME Account Opening Form

Step 1 of 5

Company

Business

Declaration

Files

Review

Step 1 of 5

Company Details

Fields marked with * are required

Registered Name *

Registration Number *

Date of Registration *

Location *

Contact Details

Postal Address *

Email *

Phone Number *

Alternative Phone *

Nominated Kin (If owner is unreachable)

First Name *

Last Name *

Date of Birth *

Gender *

Role in the Company *

Phone Number *

Step 2 of 5

Business Information

Fields marked with * are required

Type of Business *

Business Ownership Type *

Business Owners (Optional)

You can add up to 5 business owners.

Source of Capital *

Number of Employees *

Bank Account Details *

Account Name *

Account Number *

Bank Name *

Monthly Deductions

Leave blank to use default: K15,000

Deposits

Leave blank to use default: K15,000

Note: Minimum Share: K15,000 | Deposits: K15,000 | Services Fees: K3,500

Step 3 of 5

Beneficiaries

Fields marked with * are required

Main Beneficiary *

Full Name *

Date of Birth *

Relationship *

Phone Number *

Contingent Beneficiary *

The contingent beneficiary must be a different person from the main beneficiary.

Full Name *

Date of Birth *

Relationship *

Phone Number *

Note: There is a 6 months waiting period in case of natural death from the date of the first premium

Declaration by the Proposer and Life Assured

To the best of your knowledge, are you in good health? *

YES NO

I/We the person/s by whom the Assurance is to be effected, declare that to the best of my knowledge and belief: I/We am/are in good health, free from disease and disability or symptoms thereof. I/We agree that the foregoing answers and this declaration and answers to the questions put shall be the basis of contract between me/us and Co-operatives Life Assurance. I/We also understand that no natural death claim shall be payable during the first 30 DAYS from the effective date.

Acknowledgement

I hereby make Application for Membership, Funeral cover and agreed to conform to the Bye-Laws and any Amendments thereof

Step 4 of 5

File Uploads

Fields marked with * are required

ID Document Upload *

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