Know Your Customer (KYC) Company Form

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 *

Where and when was the entity formed? *

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

Type of Entity *

Public 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 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?

Yes
No

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

Completed by: *

Position: *

Date *

Signature *

Attachments (Certified Copies):

Certificate of Incorporation *

Click or drag a file to this area to upload.

Registration Certificate (for Partnerships) *

Click or drag a file to this area to upload.

Copies of ID’s of your top two position holders in your company (or two directors) *

Click or drag a file to this area to upload.

Proof of Address (utility bill / title deed / lease agreement) *

Click or drag a file to this area to upload.

Annual Financial Statements (not more than 2 years) OR Form J and Form C *

Click or drag a file to this area to upload.