KYC INDIVIDUAL FORM

Reunion Insurance Company Limited - Your First Class Insurer

Know Your Customer Form

Section 1 - To be completed by individuals/non corporates only

Part A - Personal Details

Title

Surname *

First Name *

Other Names

Maiden Name

Date of Birth *

Marital Status *

Nationality *

Status *

ID Used *

ID Number *

Part B - Location and Contact Details

Postal Address *

Physical Address *

Email Address *

District

Plot/House Number

Home District

Home T/A

Village

Cellphone No. *

Phone No.

Part C - Occupation Details

Occupation *

Employment Status *

Employer Name

Employer Address

Earnings per month

Please select one of the categoreis

Part D- Bank Details

Bank Name *

Account Number *

Branch *

Part E- Next of Kin

Full Name

Relationship

Phone Number

Email Address

Section 2: Mandatory Field

Declaration

(a) I/We hereby confirm that all the information is true, complete and accurate

(b) I/We hereby authorise Reunion Insurance Company and its designated agents and representatives to conduct credit reference checks regarding My/Our credit worthiness for the purpose of deciding whether to provide insurances on credit. I/We further authorise any individual, firm, Company, Corporation, Organization or public body to provide information regarding my/our credit worthiness to Reunion Insurance Company limited and its designated agents and representatives

Date *

Place

Signature

Clear Undo