KycIndividual Client Profile Branch * KhobarJeddahRiyadh Client/Supplier Name * ID number * Employer Name * ID Expiry date * Date of Birth * Place of Birth * Nationality * AfghanAlbanianAlgerianAmericanAndorranAngolanAnguillanArgentineArmenianAustralianAustrianAzerbaijaniBahamianBahrainiBangladeshiBarbadianBelarusianBelgianBelizeanBenineseBermudianBhutaneseBolivianBotswananBrazilianBritishBritish Virgin IslanderBruneianBulgarianBurkinanBurmeseBurundianCambodianCameroonianCanadianCape VerdeanCayman IslanderCentral AfricanChadianChileanChineseCitizen of Antigua and BarbudaCitizen of Bosnia and HerzegovinaCitizen of Guinea-BissauCitizen of KiribatiCitizen of SeychellesCitizen of the Dominican RepublicCitizen of VanuatuColombianComoranCongolese (Congo)Congolese (DRC)Cook IslanderCosta RicanCroatianCubanCymraesCymroCypriotCzechDanishDjiboutianDominicanDutchEast TimoreseEcuadoreanEgyptianEmiratiEnglishEquatorial GuineanEritreanEstonianEthiopianFaroeseFijianFilipinoFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarianGreekGreenlandicGrenadianGuamanianGuatemalanGuineanGuyaneseHaitianHonduranHong KongerHungarianIcelandicIndianIndonesianIranianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhKenyanKittitianKosovanKuwaitiKyrgyzLaoLatvianLebaneseLiberianLibyanLiechtenstein citizenLithuanianLuxembourgerMacaneseMacedonianMalagasyMalawianMalaysianMaldivianMalianMalteseMarshalleseMartiniquaisMauritanianMauritianMexicanMicronesianMoldovanMonegasqueMongolianMontenegrinMontserratianMoroccanMosothoMozambicanNamibianNauruanNepaleseNew ZealanderNicaraguanNigerianNigerienNiueanNorth KoreanNorthern IrishNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New GuineanParaguayanPeruvianPitcairn IslanderPolishPortuguesePrydeinigPuerto RicanQatariRomanianRussianRwandanSalvadoreanSammarineseSamoanSao TomeanSaudi ArabianScottishSenegaleseSerbianSierra LeoneanSingaporeanSlovakSlovenianSolomon IslanderSomaliSouth AfricanSouth KoreanSouth SudaneseSpanishSri LankanSt HelenianSt LucianStatelessSudaneseSurinameseSwaziSwedishSwissSyrianTaiwaneseTajikTanzanianThaiTogoleseTonganTrinidadianTristanianTunisianTurkishTurkmenTurks and Caicos IslanderTuvaluanUgandanUkrainianUruguayanUzbekVatican citizenVenezuelanVietnameseVincentianWallisianWelshYemeniZambianZimbabwean Details of the client Source of Fund * SalaryOthers Details of the client purpose of this relationship * InsuranceOthers Is the client from one of Internationally prohibited countries? * Yes No If Yes is select proper Authorization Document should be attached. Drop a file here or click to upload Choose File Maximum file size: 1MB Is the client classified as PEP*? * Yes No If Yes please provide details of the Name and the reason Drop a file here or click to upload Choose File Maximum file size: 1MB Is the polciy holder acting on his on behalf? * Yes No If Yes please provide details and documented authorization Drop a file here or click to upload Choose File Maximum file size: 1MB National Adress Information: Address * Building No * Unit No * Zip code * Additional No * Contact Information: Contact Name * Email address * Country Code * AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBritish Virgin Is.BruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African Rep.ChadChileChinaColombiaComorosCongo, Dem. Rep.Congo, Repub. of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Fed. St.MoldovaMonacoMongoliaMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaN. Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts & NevisSaint LuciaSt Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabwe Mobile telephone * Web Page File Upload Drop a file here or click to upload Choose File Maximum file size: 2MB Client Bank Details: Bank * Saudi National BankThe Saudi British Bank (SABB)Saudi Investment BankAlinma bankBanque Saudi FransiRiyad BankAl Rajhi BankArab National BankBank AlBiladBank AlJaziraOthers. Branch * AlKhobarJeddahRiyadh Other Bank Name * Swift Code IBAN Number (Should be 24 Characters) * * 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 ID must be provided” * Drop a file here or click to upload Choose File Maximum file size: 1MB Name * Signature and Stamp * signature keyboard Clear * 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. Captcha Submit If you are human, leave this field blank.
