KNOW YOUR CUSTOMER (KYC) FORM

IMPORTANT INFORMATION:

An insurance agent who assists an applicant to complete an application or proposal or KYC form for insurance shall be deemed to have done so as an agent of the applicant in accordance with section 54 (2) of Insurance Act 2003.

The liability of Heirs Life Assurance Limited does not commence until this application is accepted and the premium is paid in accordance with section 50 (1) of Insurance Act 2003.

Name of Firm/Institution:

Address of Principal Place of Business Operation (Please do not indicate P.O.Box No.):

Town/City:

State:

Country:

Incorporation/Reg. No.:

Date of Incorporation:

State of Incorporation/Reg. (If applicable):

Country of Incorporation/Reg.:

Type of Business:

Operating Business Telephone 1:

Operating Business Telephone 2:

Email:

Fax (If available):

Website:

Tax Identification Number (TIN):

Bank Verification Number (BVN):

Bank Account Number:

Name of Bank:

Branch of Bank:

Risk Location Address (If applicable):

Type of Cover:

Period of Cover:

Number of Beneficiaries:

Beneficiary(ies) (Payee of claims if materialized):

IDENTIFICATION: submit the following documents along with the completed form

Certificate of Incorporation/Registration:

CAC Form C07:

Memorandum/Article of Association:

CAC Form C02:

Copy of authorization to operate issued by the relevant regulatory body (if applicable):

DIRECTORY/SIGNATORY PROFILE

Surname:

First Name:

Middle Name:

Gender:

Male

Female

Date of Birth

Nationality:

Tax No.:

Phone No.:

Occupation:

Email:

Means of Identification:

Driver's License:

National ID:

International Passport:

ID Number:

ID Country:

Issue Date:

Expiry Date:

DECLARATION:

We hereby declare and confirm that the information supplied above are true to the best of our knowledge.

Authorized Signature & Stamp:

Date:

Name: