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Kyc Form - 032522

The document is a KYC form for customer profiling at NICON Insurance, requiring personal information such as name, contact details, occupation, and identification. It also includes sections for account officer verification and a visitation report to confirm the customer's address. Additionally, there is a utility waiver for customers who do not possess a utility bill in their name.

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Aaron Kure
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25 views3 pages

Kyc Form - 032522

The document is a KYC form for customer profiling at NICON Insurance, requiring personal information such as name, contact details, occupation, and identification. It also includes sections for account officer verification and a visitation report to confirm the customer's address. Additionally, there is a utility waiver for customers who do not possess a utility bill in their name.

Uploaded by

Aaron Kure
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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KYC FORM – CUSTOMER PROFILE

Customer’s Name:
------------------------------------------------------------------------------------------------

Account/Policy №: -----------------------------------------------------------------------------------------------

Gender: --------------------- ---------------- Marital Status: -------------------------------------------------


Religion: --------------------------------------- Date of Birth: --------------------------------------------------

Nationality: -------------------------------------- Tel: -----------------------------------------------------------

E-mail:--------------------------------------------------------------------------------------------------------------

Address (Home) --------------------------------------------------------------------------------------------------

Occupation / Profession: ----------------------------------------------------------------------------------------

Name of Company: ----------------------------------------------------------------------------------------------

Address (Office): -------------------------------------------------------------------------------------------------

BVN (For Corporate Entity):-----------------------------------------------------------------------------------

TIN (For Corporate Entity):------------------------------------------------------------------------------------

Source of Funds:
Individual: Salary Business Income Sales of Property Other
Corporate: Trading Retailing Others
Other sources of income apart from occupation:
Investments Dividends
Who introduced you to NICON Insurance Limited? --------------------------------------------------------

Customer Identification (i.e)

National Identity Card Driver’s License

International Passport Residence/Work Permit (PLS TICK AS


APPLICABLE)

a) Number ---------------------------------------------------------------------------------------------------
b) Date of Issue ---------------------------------------------------------------------------------------------
c) Expiry Date
-----------------------------------------------------------------------------------------------
d) Country of Issuance -------------------------------------------------------------------------------------

FOR OFFICE USE ONLY


I------------------------------------------------------------the account officer
of--------------------------------
------------------------------who is a prospective customer of NICON Insurance Ltd, do
hereby certify that I have carried out relevant verification to establish the identity,
address and nature of business of the customer and his/her eligibility as a policy
holder with NICON Insurance Ltd.

I also certify that the applicant(s) is engaged in (nature of


business)------------------------------------

It shall be my responsibility to continuously monitor the account/policy holder’s


activity and inform the MD, if at any point in time, there is (are) profound change(s) in
the standing of the Account/Policy holder(s) and/or suspicious transaction as required
by statutory regulation.
Name & Signature of Account/Policy
holder------------------------------------------------------------------
Date-----------------------------------------------------------------------------------------------------------------

VISITATION REPORT
Customer’s
Name--------------------------------------------------------------------------------------------------

Nature of
Business------------------------------------------------------------------------------------------------

Address (Not P.O.Box or


PMB)-----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------
Account Officer (Name &
Designation)------------------------------------------------------------------------

Date
visited--------------------------------------------------------------------------------------------------------

Description--------------------------------------------------------------------------------------------------------
-
(Of the address/location e.g state the colour, type of building & other landmark for
unique identification)

Are you convinced that customer Resides at/connected with the above
address---------------------

Account officer’s
signature---------------------------------------------------------------------------------------

UTILITY WAIVER
Date:.................................

The Managing Director,


NICON Insurance Ltd,
NICON Plaza,
Plot 242, Muhammadu Buhari Way,
Central Business District,
Abuja – FCT.

Dear Sir,

RE: UTILITY BILL

I wish to inform you that I do not have any utility bill made out in my name.
Kindly oblige my account opening without utility bill.

Signature & Date .........................................................

Name: ........................................................................

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