Account Opening and KYC Form (Individuals)

Chubb Branch *

ID Number *

First Name *

Middle Name *

Last Name *

Employer Name *

ID Expiry Date *

Date Of Birth *

Place Of Birth *

Nationality *

Details Of the Client Source Of Fund *

Details of the client purpose of this relationship *

Is the client from one of Internationally prohibited countries?

Yes

Is the client classified as PEP?

Yes

Is the polciy holder acting on his on behalf?

Yes

National Address Information:

Address *

Building No

Unit No

Zip Code

Additional No

Contact Information:

Contact Name *

Email *

Mobile Number *

Web Page

File Upload

Client Bank Details:

Bank *

Branch *

Swift Code*

IBAN Number (Should be 24 Characters) *

Must be 24 characters long, start with two English letters, followed by 22 digits.

I/We declare that the above mentioned information and statements are true and correct to the best of knowledge of the undersigned and it has been made in good faith. I further declare and accept that Chubb Company. Will depend on this information in order for them to fulfil as well their regulatory obligations.

A) Declaration and Knowledge:

I hereby declare that the above provided information is true to the best of my knowladge and and on that I sign

I have read and understood the contents of this Consent Form and hereby provide my explicit consent for the collection, processing, and sharing of my personal and sensitive personal information by Chubb Arabia following the terms outlined above.

ID must be provided *

Name *

Signature and Stamp *

* PEP : A member of the royal family, ministers, government leaders or political opponents
* Kindly note that AML deparment could request more docuemts if it is necessry.