MAPFRE | INSULAR KYC Form Dear Valued Client Please be informed that Republic Act 9140, otherwise known as the Anti-Money Laundering Act AMLA"I, requires that insurance companies keep basic information of all assured, To comply wth ths all member companies ofthe Philippine Insurers & Reinsurers Assaciation [PRA] have adopted common ‘Know Your Client" [KYC] forms for individual and corporate clients. In this regard, we request that you fil-out the Client Information Sheet below. Please be assured that al information willbe heldin strict confidence. The KYC form shall be valid and retained for five 5] years unless there ae changes inthe declared information, Please disregard this letter f you have already filled out & KYC form. For your conveniance, we are providing you withthe fllowing options in returning the KYC form 1 "Send to any MAPFRE insular branch c/o The Branch Head 2. Send through your servicing agent or broker 3. Fax to 632)8 76-4344 clo "Ihe Compliance Officer 4. Email tokye@mapfreinsularcom ‘Thank you for your cooperation and we look forward ta receiving your KYC form, Very truly yours, MAPERE INSULAR INSURANCE CORP. FOR INDIVIDUAL CLIENT Present Address No, Street District Town City/Province Zin Code [Residence Tet. No Permanent Address Mobile No Nationality Date of Birth: Imen/dayyl Place of Birth TN ‘S9S/G5I5 Ne, Email Name of Employer Nature of Self Employment / Business Source of Funds Name of Beneficiaries, applicable Business Name Contact Nes, Principal Business Address: Nature of Business: TIN, List of Board of Diectore/Partners List of Principal Stockholders owning a least 236 ofthe capital stock Beneficial Owners, any Certified True and Correct: A Contacto. Name & Signature of Insured/Corporate representative Pesto Spel compan tcantate nor santa rap ps nag ayn al of taps ny ora ama ahorn Date Signed Policy No.