KYC FORM

INDIVIDUAL CLIENT

BRANCH __________________________________________________________________________________________________________________________

S/N KYC ITEMS REMARKS

1 Surname

2 Other Names

3 Title (e.g Mr, Mrs, Dr. etc)

4 Insured’s Date Of Birth

5 Business Address

6 Home Address

7 Email Address

Mobile Number And Other

8
Telephone Numbers

9 Business/Profession

10 Policy Type

11 Lead Agent/broker’s Name

Identification Item (Driver’s Licence,

12 International Passport Or National Id
Card) Of At Least Two Directors.

13 Name Any Existing Policy (if any)

I hereby certify that the information provided is to the best of my knowledge true and correct.

Name__________________________________ Status___________________ Sign_________________________ Date_______________________

CLIENT RELATIONSHIP OFFICER

Name__________________________________ Position___________________ Sign_________________________ Date_______________________

MANAGEMENT

Name__________________________________ Position___________________ Sign_________________________ Date_______________________

NOTE: TBA (To be advised) will not be acceptable in any of the fields under any circumstance.