Know Your Customer - Corporate - Tibiyo Insurance Brokers

Prepared by Tibiyo Insurance Group (pty) Limited to comply with the Money Laundering and Terrorist Financing (Prevention) Act, 2011)

Registered name and Trading name of Entity *

When and where was the entity formed

Company ownership names and structure, (to include shareholding percentage) *

Type of Entity *

Private Company
Limited Liability Private Company
Partnership
Association

Where Applicable: Names of people holding the two highest positions in your Company (i.e. CEO, MD, CFO) *

Brief description of your business? *

Physical address of Business

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Main Office address/telephone/fax/email/website:

Phone *

Fax *

Email *

Website / URL

Are any of your Company Directors entrusted with prominent public functions such as being a Member of Parliament, Government Minister/s, Judge/s, and high ranking member of the armed forces and senior official/s of state-owned enterprises?

If your answer to the above question is yes, please provide more details

Completed by *

Position

Date / Time *

Signature

Attachments - Certified Copies

Certificate of Incorporation *