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    Know Your Client (KYC) - Individual

    Uploaded by

    Reggie Cayco

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Know Your Client (KYC) - Individual

    Uploaded by

    Reggie Cayco
    9 views1 page

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    9 views1 page

    Know Your Client (KYC) - Individual

    Uploaded by

    Reggie Cayco

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    F-SUP-01

    Revision No. 08
    Revision Date: November 01, 2022

    CLIENT INFORMATION “KYC FORM” FOR INDIVIDUAL CLIENT


    Client information as mandated under the Phil. Anti-Money Laundering Act (AMLA).
    Complete information required before a policy is issued
    Complete Name: (First Name, Middle Name, Surname) Citizenship or Nationality:

    Present Address:
    Permanent Address:

    Contact Nos.: TIN:

    E-mail Address: SSS, GSIS, Driver’s License or Passport No. (For


    Driver’s License and Passport, please indicate “Date of Expiry”):

    Date of Birth Place of Birth Sex ( ) Male ( ) Female Civil Status:

    Nature of Work Name of Employer

    Nature of Self-Employment/Business
    Sources of Funds
    Do you have an existing agent with BPI/MS? ☐ None ☐ Yes Agent’s Name:
    BENEFECIARY AND/OR BENEFICIAL OWNER, if applicable
    Complete Name: (First Name, Middle Name, Surname) Citizenship or Nationality

    Relationship to the assured:


    Address

    Contact Nos. TIN SSS, GSIS, Driver’s License or Passport No. (For
    Driver’s License and Passport, please indicate “Date of Expiry”):

    Date of Birth Place of Birth Sex ( ) Male ( ) Female


    Nature of work Source of Funds
    Assured/Client Signature Date Policy No.

    To be accomplished by BPI MS Personnel / Agent


    Identification documents validated against originals by (Attach copy of Client ID No.
    Identification documents)

    Signature over Printed Name

    Data Privacy. Pursuant to the foregoing Application, I consent to the collection, use, processing and transfer of my personal data as described
    in this paragraph and in accordance with the Data Privacy Act of 2012 (R.A. 10173). I understand that the Company and/or its related companies
    hold certain personal information about me (including my name, address and telephone number, date of birth, social security number, tax
    identification number, etc.) for the purpose of processing my Insurance Cover. I also understand that the Company may transfer this Data
    amongst its related companies as necessary for the purpose of processing, administering and managing my Insurance Cover, and that the
    Company may also transfer this Data to any third party assisting the Company in the processing, administration and management of my
    insurance. I authorize them to receive, possess, use, retain and transfer the Data, in electronic or other form, for these purposes. I also
    understand that I may, at any time, review the Data, require any necessary changes to the Data or withdraw my consent in writing by contacting
    the Company. I further understand that withdrawing my consent may substantially affect my ability to further process and collect on my
    insurance. The full BPI/MS Privacy Policy can be found at www.bpims.com.

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