English Central Kyc Form
English Central Kyc Form
English Central Kyc Form
2. TICK IF APPLICABLE RESIDENCE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA (Please refer instruction B at the end)
B- Voter ID Card
C- PAN Card
D- Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar)
F- NREGA Job Card
Z- Others (any document notified by the central government) Identification Number
S- Simplified Measures Account - Document Type code Identification Number
Line 1*
Line 2
Line 3 City / Town / Village*
District* Pin / Post Code* State / U.T Code* ISO 3166 Country Code*
4.3 ADDRESS IN THE JURISDICTION DETAILS WHERE APPLICANT IS RESIDENT OUTSIDE INDIA FOR TAX PURPOSES* (Applicable if section 2 is ticked)
Same as Current / Permanent / Overseas Address details Same as Correspondence / Local Address details
Line 1*
Line 2
Line 3 City / Town / Village*
State* ZIP / Post Code* ISO 3166 Country Code*
6. DETAILS OF RELATED PERSON (In case of additional related persons, please fill ‘Annexure B1’ ) (please refer instruction G at the end)
Addition of Related Person Deletion of Related Person KYC Number of Related Person (if available*)
Related Person Type* Guardian of Minor Assignee Authorized Representative
Prefix First Name Middle Name Last Name
Name*
(if KYC number and name are provided below details of section 6 are optional)
PROOF OF IDENTITY [PoI] OF RELATED PERSON* (Please see instruction (H) at the end)
B- Voter ID Card
C- PAN Card
D- Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar)
F- NREGA Job Card
Z- Others (any document notified by the central government) Identification Number
S- Simplified Measures Account - Document Type code Identification Number
7. REMARKS (If any) Mobile no. / Email-ID) (Please refer instruction F at the end)
8. APPLICANT DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes
therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable
for it. [Signature / Thumb Impression]
I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address.
Date D D M M Y Y Y Y Name
Emp. Name Code
Emp. Code
Emp. Designation
Emp. Branch
[Institution Stamp]
[Employee Signature]
CENTRAL KYC REGISTRY | Instructions / Checklist / Guidelines for filling Individual KYC Application Form
General Instructions:
1 Fields marked with ‘*’ are mandatory fields.
2 Tick ‘ü ’ wherever applicable.
3 Self-Certification of documents is mandatory.
4 Please fill the form in English and in BLOCK Letters.
5 Please fill all dates in DD-MM-YYYY format.
6 Wherever state code and country code is to be furnished, the same should be the two-digit code as per Indian Motor Vehicle, 1988 and ISO 3166 country code respectively list
of which is available at the end.
7 KYC number of applicant is mandatory for updation of KYC details.
8 For particular section update, please tick (ü ) in the box available before the section number and strike off the sections not required to be updated.
9 In case of ‘Small Account type’ only personal details at section number 1 and 2, photograph, signature and self-certification required.
B Clarification / Guidelines on filling details if applicant residence for tax purposes in jurisdiction(s) outside India
1 Tax identification Number (TIN): TIN need not be reported if it has not been issued by the jurisdiction. However, if the said jurisdiction has issued a high integrity number with
an equivalent level of identification (a “Functional equivalent”), the same may be reported. Examples of that type of number for individual include, a social security/insurance
number, citizen/personal identification/services code/number, and resident registration number)
D Clarification / Guidelines on filling ‘Proof of Address [PoA] - Current / Permanent / Overseas Address details’ section
1 PoA to be submitted only if the submitted PoI does not have an address or address as per PoI is invalid or not in force.
2 State / U.T Code and Pin / Post Code will not be mandatory for Overseas addresses.
3 In case of Simplified Measures Accounts for verifying the address of the applicant, any one of the following documents can also be submitted and undernoted relevant code
may be mentioned in point 4.1.
Document Code Description
01 Utility bill which is not more than two months old of any service provider (electricity, telephone, post-paid mobile phone, piped gas,
water bill).
02 Property or Municipal Tax receipt.
03 Bank account or Post Office savings bank account statement.
04 Pension or family pension payment orders (PPOs) issued to retired employees by Government Departments or Public Sector
Undertakings, if they contain the address.
05 Letter of allotment of accommodation from employer issued by State or Central Government departments, statutory or regulatory
bodies, public sector undertakings, scheduled commercial banks, financial institutions and listed companies. Similarly, leave and
license agreements with such employers allotting official accommodation.
06 Documents issued by Government departments of foreign jurisdictions and letter issued by Foreign Embassy or Mission in India.
E Clarification / Guidelines on filling ‘Proof of Address [PoA] - Correspondence / Local Address details’ section
1 To be filled only in case the PoA is not the local address or address where the customer is currently residing. No separate PoA is required to be submitted.
2 In case of multiple correspondence / local addresses, Please fill ‘Annexure A1’
H Clarification / Guidelines on filling ‘Related Person details – Proof of Identity [PoI] of Related Person’ section
1 Mention identification / reference number if ‘Z- Others (any document notified by the central government)’ is ticked.
List of two – digit state / U.T codes as per Indian Motor Vehicle Act, 1988
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual | Correspondence / Local Address
Important Instructions:
A) Fields marked with ‘*’ are mandatory fields. E) List of State / U.T code as per Indian Motor Vehicle Act, 1988 is available at the end.
B) Please fill the form in English and in BLOCK letters. F) List of two character ISO 3166 country codes is available at the end.
C) Please fill the date in DD-MM-YYYY format. G) KYC number of applicant is mandatory for update application.
D) Please read section wise detailed guidelines / instructions H) For particular section update, please tick ( ) in the box available before the
at the end. section number and strike off the sections not required to be updated.
2. CONTACT DETAILS (All communications will be sent on provided Mobile no./ Email-ID) (Please refer instruction F at the end)
3. APPLICANT DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes
therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held
liable for it.
[Signature / Thumb Impression]
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual | Related Person
Important Instructions:
A) Fields marked with ‘*’ are mandatory fields. E) List of State / U.T code as per Indian Motor Vehicle Act, 1988 is available at the end.
B) Please fill the form in English and in BLOCK letters. F) List of two character ISO 3166 country codes is available at the end.
C) Please fill the date in DD-MM-YYYY format. G) KYC number of applicant is mandatory for update application.
D) Please read section wise detailed guidelines / instructions H) For particular section update, please tick ( ) in the box available before the
.at the end. section number and strike of the sections not required to be updated.
Addition of Related Person Deletion of Related Person KYC Number of Related Person (if available*)
Related Person Type* Guardian of Minor Assignee Authorized Representative
Prefix First Name Middle Name Last Name
Name*
(If KYC number and name are provided, below details of section 1 are optional)
PROOF OF IDENTITY (PoI) OF RELATED PERSON* (Please see instruction (H) at the end)
B- Voter ID Card
C- PAN Card
D- Driving Licence Driving Licence Expiry Date D D M M Y Y Y Y
E- UID (Aadhaar)
F- NREGA Job Card
Z- Others (any document notified by the central government) Identification Number
S- Simplified Measures Account - Document Type code Identification Number
2. APPLICANT DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes
therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held
liable for it. [Signature / Thumb Impression]
Date D D M M Y Y Y Y Name
Emp. Name Code
Emp. Code
Emp. Designation
Emp. Branch
[Institution Stamp]
[Employee Signature]
Mailing Address: ICICI Lombard Healthcare, ICICI Bank Tower, Plot No. 12, Financial District, Nanakram Guda, Gachibowli, Hyderabad-500032
Registered Office Address: ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at: www.icicilombard.com. • E-Mail us at: ihealthcare@icicilombard.com.• Toll Free Number: 1800 2666.
• Toll Free Fax Number: 1800-209-8880 • IRDA Registration No. 115