INSURANCE COMPANY OF NORTH AMERICA

A Chubb Company
24th Floor Zuellig Building, Makati Avenue Corner
Paseo de Roxas Makati City 1226, Philippines

CLIENT INFORMATION FORM

GENERAL INFORMATION INPUT BY REQUESTOR

Request Type New Update Termination

Requestor Name
Department

ACCOUNT INFORMATION INPUT BY CLIENT

Client Name
Address
City
Postal Code
Country
Telephone/ Mobile Number
Business Contact Name

BANK DETAILS: INPUT BY CLIENT

Bank Country
Bank Name
Bank Branch
Swift Code
Account Name
Bank Account Number
Payment Currency
Remittance Email address

CLIENT'S DECLARATION

Signature Over Printed Name

Date

FOR FINANCE USE ONLY

BIR 2303 /Registration (for New )

Updated in PeopleSoft
Business Permit Vendor Masterfile

SEC (for Corporate), DTI (for Individual) Vendor ID

Bank Details

Contract Agreement Reviewed By:

Other Vendor Information

Approved By:

Chubb_Ph_Finance_10.10.2018_G:\Finance\Finance Files\VENDOR MASTER FILE\Vendor Information Form