KYC DUE-DILIGENCE NATURAL

GENERAL INFORMATION

Name:

Sex:

Birthdate (dd/mm/yyyy)

ID Card / Passport No.

Nationality:

Maintains another nationality:

Other Passport:

Country of domicile:

Physical address:

Profession:

Workplace:

Position:

Civil Status:

Email:

SPOUSE OR PARTNER INFORMATION

Name:

Birthdate (dd/mm/yyyy)

Passport number:

Nationality:

POLITICALLY EXPOSED PERSON

You are or have been a Politically Exposed Person? (PEP):

FINANCIAL PROFILE

Annual income main activity:

Less of 10 thousand US$10 thousand to 30 thousand US$30 thousand to 50 thousand US$More than 50 thousand US$

Annual income from other activities:

Less of 10 thousand US$10 thousand to 30 thousand US$30 thousand to 50 thousand US$More than 50 thousand US$

Passport Copy

Have a second nationality, must provide a copy of the passport.

STATEMENT

"I DECLARE THAT THE INFORMATION CONTAINED IN THIS FORM IS TRUE, COMPLETE AND PROPORTIONATE.
RELIABLE AND UP-TO-DATE INFORMATION ON ALL ASPECTS ON WHICH QUESTIONS HAVE BEEN ASKED."

The applicant declares that:

Has not been involved in, has not been convicted of or is under investigation anywhere in the world for offences related to the production, trafficking, consumption of drugs or any other offence associated with drugs; or money laundering.

I (we) confirm that I (we) have and verify the due diligence evidence of all beneficial owners, attorneys, beneficiaries, directors, officers and signatories of the services necessary for ACTIVE-RE; and agree to provide such information and/or documentation requested by ACTIVE-RE.

I declare under penalty of perjury that this statement has been examined by me and is true, correct and complete to the best of my knowledge and belief.

Please complete the form and print and send signed to the e-mail compliance@acreinsurance.com.