KYC DUE-DILIGENCE NATURAL Email GENERAL INFORMATION Name: * Sex: * Female Male Birthdate (dd/mm/yyyy) * ID Card / Passport No. * Nationality: * Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Maintains another nationality: * Yes No Other Passport: Country of domicile: * Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Physical address: * Profession: * Notary Attorney or Legal Advisor who handles third-party funds Notary or Legal Advisor who DOES NOT handle third-party funds Theater theater circus and valet theater arranger Actuary Business administrator Farm manager Third-party funds administrator Telephone marketing agent Call Center Security agent private escort company private surveillance guard keeper other Insurance agent Insurance consultant Insurance broker Sales agent Travel agent tours local tours international other Auction and auction agents Farmer Potter Housewife Accounting financial analyst for collection credit systems other Architect Wage earners in general Advisor or Consultant Financial Assistant of Commercial Management Audit Human Resources Legal other Auditor Assistant Dancer Actor Producer Librarian Biologist Firefighter Cashier Ship captain Heavy machinery driver Driver of urban transport: buses, taxis and others Chef Accountant who manages funds for third parties Accountant who does NOT handle funds for third parties Accountant Air traffic controller Chief supervisor coordinator or manager Interior and exterior decorator Economic dependent Minor Dependents Dispatcher Athlete Graphic designer Display and stevedores Newspaper distributor Teachers in general Financial Economist Periodical advertising editor or magazine others Executive Packer Independent Business Owner Paramedic Nurse Lifeguard Frame framer Stylist and cosmetologist Students Pharmaceutical Physiotherapist Plumber Cameraman Photographer Banking officer Public Official who is not considered in the PEP category Geographer Geologist Manager Collection Manager Park Ranger National and international tourism guide Tinsmith Engineer Inspector Instructor acondicionamiento fìsico artes marciales defensa personal gimnasia natación otros Investor Detective Investigator Gardener Pruning and felling Jeweler Clinical chemistry laboratory other Announcer and animator Magician clowns and circus staff Machinist Sailor Butler Housekeeper Automotive mechanic assistant apprentice boss others Aviation mechanic Doctor Delivery Messenger Marketing Waiter waitress waiter Meteorologist Microbiologist Missionary Musicians and diskjokey Nutritionist Dentists and Orthodontists Compliance officer Office worker Operator Goldsmith Homeroom Baker Retired Journalist Reporter Real Estate Appraisers Individual who carries out sporadic activities Airplane crew Pilot Copilot Captain Stewardess Aeromoza Boarding officer Overload others High-level teaching staff Director Vice-rector Rector Decano Professor Other Military personnel Official Cadet Captain General others People Exposed Politically PEP's Individuals who receive income from investment interests Craft fisherman Police Preacher Religious Priest Nun Sor Sister Religious Fraile Brother Lender Professional in art sketcher painter musician writer other Programmer Promoter artistic tourist sports other Propietario bar club nocturno restaurante otros Publicist Receptionist Public or International Relations Tailor Sercretary Technical translation and language services Maritime overfill Sociologist Anthropologist Archaeologist Politologist Welder Worker with electric saw Turner Sub-Manager Tattoos body piercing decorators Technical Telephone Call Center Treasurer Surveyor Specialized worker Social Worker Psychologist Psychiatrist Translator Carrier trailer tanker truck others Lottery seller Arms dealers Sellers of art and antiques Sellers of used cars and trucks Sellers of precious stones and metals Sellers of new motor vehicles Vet N/A Workplace: * Position: * Civil Status: * Single Married United Email: * SPOUSE OR PARTNER INFORMATION Name: Birthdate (dd/mm/yyyy) Passport number: Nationality: Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe POLITICALLY EXPOSED PERSON You are or have been a Politically Exposed Person? (PEP): * Non-PEP PEP with more than two years of not practicing as PEP Person related (up to second degree of consanguinity or affinity) with a PEP with more than two years of not pacticing as PEP PEP in exercise PEP with less than two years of not practicing as PEP Person related (up to second degree of consanguinity or affinity) with some PEP in exercise Person related (up to second degree of consanguinity or affinity) with some PEP with less than two years of not practicing as 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. Print and SendClear Form