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: (*)
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: (*)
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