KYC CORPORATE FORM

Reunion Insurance Company Limited - Your First Class Insurer

Know Your Customer Form

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

Part A - Company Details

TPIN Number *

Company Registration Number *

Company Type *

If Company Type is "other" specify

Industry Type *

If Industry type is "other" specify

Company Name *

Date of Incorporation *

Source of Funds *

Company Ownership *

Memorandum of Understanding & Articles of Association *

Please upload memorandum of understanding & Articles of Association

Part B - Location and Contact Details

Postal Address *

Physical Address *

Email Address *

District *

Plot/House Number *

Status *

Cellphone No. *

Phone No.

Part C- Bank Details

Bank Name *

Account Number *

Branch *

Bank Name

Account Number

Branch

Part D- Contact Person

Full Name *

Position *

Email Address *

Phone Number *

Nationality *

Status *

Identification used *

ID Number *

Part E - Authorised Signatories

Authorised Signatory Position(1) *

Authorised signature (1) *

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Authorised Signatory Position(2)

Authorised Signature (2)

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Authorised Signatory Position (3)

Authorised Signature (3)

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Part F - 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 *

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