CORPORATE KYC FORM – HGI

0700 434 7746

wecare@heirsgeneralinsurance.com

09122222200

CORPORATE KYC FORM

Please answer ALL questions in full. Use CAPITAL LETTERS.

COMPANY/BUSINESS DETAILS

Name of Company: (*)

Mobile Number: (*)

Mobile Number(2):

Official Address: (*)

Website:

Email: (*)

Date of Registration: (*)

Incorporation No: (*)

Tax ID Number: (*)

Nature of Business: (*)

Bank Name: (*)

Account Number: (*)

DIRECTOR'S INFORMATION

Name of Director:

Surname: (*)

First Name: (*)

Middle Name: (*)

Address: (*)

Mobile Number: (*)

BVN: (*)

Gender: (*)MaleFemale

Date of Birth: (*)

Nationality: (*)

POLITICAL ACTIVITIES

Is Customer a PEP? (*)YesNo

If Yes, PEP Category? (*)

DOCUMENT TO BE UPLOADED

Certificate of Incorporation/Registration (*)

Utility Bill (*)

Valid ID (*)

Select your Identity Card (*)Driver's LicenseNINInt'l PassportVoter's Reg. Number

Upload your Identity Card (*)

NB: I/We hereby declare that the above particulars and answers are true and complete in every respect, and no information has been suppressed or withheld. I/We consent that my personal information can be used in line with Heirs General Insurance Data Privacy Policy. See details of the policy on www.heirsinsurancegroup.com/privacypolicy

Name of Representative (*)

Signature: (*)

Date: (*)