Horizon International Insurance

IDENTIFICATION INFORMATION:

1. Provide us with Proof of Identity (any of the following as applicable):

National Identity Card Valid Passport Certificate of Incorporation/Registration Business License

Upload Proof of Identity:

2. Provide us with Proof of Address (issued in the last 3 months):

Water bill Electricity bill Landline telephone bill Landline internet bill Valid lease agreement

Upload Proof of Address:

NB. Copies of documents requested should be certified as true copy of the original by an independent certifier unless the originals were seen at the time of inception/renewal of policy by us or our broker/agent.

CUSTOMER DECLARATIONS:

3. I / We hereby declare that I or my Immediate Family Members, or in the case of legal persons, Any Beneficial Owner, Shareholders, Nominees, Directors, Their Immediate Family Members or Close Associates, ARE NOT Politically Exposed Persons (PEPs).

4. I / We hereby declare that the source of wealth/income used to transact with Horizon International Insurance PCC Ltd or their broker/agent DO NOT CONSTITUTE the proceeds of money laundering, terrorist activities or any other illegal or criminal activities.

NB. Please indicate and provide more information if your circumstance(s) do not meet any of declaration 3 or 4.

Full Client Name (and official title/position if signing on behalf of a Company)

Date

KYC Form

KNOW YOUR CUSTOMER (KYC) FORM

IDENTIFICATION INFORMATION:

CUSTOMER DECLARATIONS: