KNOW YOUR CUSTOMER (KYC) FORM

IMPORTANT

An Insurance Agent who assists an applicant to complete an application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act 2003.Please answer ALL questions in full. Use CAPITAL LETTERS.

Name:

Title:

Home Address:

Office Address:

Home Telephone:

Office Telephone:

Email:

Date of Birth:

Gender:

Religion:

Nationality:

State:

L.G.A.:

Town:

Profession/Occupation:

Designation:

Type of Employment:

EmployeeSelf Employed

If Employee, Name of Employer:

Address of Employer:

Date of Employment:

Employer's Tel. No.:

Marital Status: MarriedSingleDivorcedSeparated

Please if married, give the following:

Name of Spouse:

Wedding Anniversary:

Spouse Date of Birth:

Next of Kin:

Type of Residence: OwnerTenant

Documents to be Submitted:

Electricity Bill:

Any of the following Personal Identification Cards: Driver's LicenseNational IDInternational Passport

Upload Personal Identification Cards:

Social & Political Activities:

Which Social/Membership club do you belong:

Do you or your spouse belong to any political or pressure group? YesNo

Does any of your close relations belong to any political or pressure group? YesNo

FatherMotherUncleIn-LawWifeHusbandBrotherSister

I consent that my personal information can be used in line with Heirs Insurance Data Policy.
See details of the policy.

Customer's Signature:

Date:

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