KNOW YOUR CUSTOMER: INDIVIDUALS

Please use black pen and block letters. TICK APPROPRIATE BLOCK UNLESS OTHERWISE INDICATED

D D M M Y Y Y Y
Form last completed in Polic Number

SECTION A: IDENTITY DETAILS

Title

Name(s) Surname

Date of Birth Nationality

Omang /
Passport Number

SECTION B: ADDRESS AND CONTACT DETAILS

Postal Address

Current Physical Address

Village / Town / City District

Country

Duration if less than 2 years

of stay give previous residential address

Permanent Address

Telephone Mobile

Fax Email Address

Employer Place of Work

Occupation Work Tel No.

Profession

SECTION C: BANKING DETAILS

Bank Name Branch

Account Number Account Type

Source of Income / Wealth

Employment/Salary Property Inheritance

Savings Other investments e.g. shares, unit trusts etc

Other, please specify

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 President
ANTI- MONEY LAUNDERING AND COUNTER
Vice President
TERRORIST FINANCING REQUIREMENTS
Cabinet Minister

In accordance with the Financial Intelligence Regulations, the following Speaker or National Assembly
documents should be provided for verification:
Debut Speaker of National Assembly
Natural Persons Member of National Assembly

1. Identification document within 6 months validity i.e. Certified Councilor

Oman for citizens; Certified Passport including work and residence Senior Government Official
permit or exemption for foreign nationals; Certified Refugee
Identity card for refugees Judicial Officer
2. Proof of source of funds/income i.e. payslip (not older than
3 months); recent 3 months bank statements, letter from
Kgosi
employer(not older than 3 months).
3. Proof of residence i.e. utility bill (not older than 6 months); valid Senior Executive of a Private entity
lease agreement (within lease period); letter from employer (not
Senior Executive of a Public Body
older than 3 months); letter from Tribal Authority: Affidavit from
Commissioner of Oaths; Title Deed: Council rates receipt Senior Executive of a Political Party
4. Certified Birth Certificate for policies taken out under the name of
Senior Executives of International Organisations Operating in Botswana,
a minor child.
or such person as may be prescribed

Companies
PIP IN YOUR IMMEDIATE FAMILY OR CLOSE ASSOCIATES
• Certification of incorporation
• Memorandum and Articles of Association / Constitution This includes all people that have been entrusted with prominent public function or
• Notice of Registered office and Postal Address an individual who is a close associate o immediate family member to that person.
• Identification documents of the persons managing the company
• Resolution specifying who is authorized to act on behalf o
company Full name
• Identification documents) of the person(s) authorized to act on
behalf of the company
• Shareholder certificate Address
• Tax clearance certificate
• Details of registered office and place or business
Title
Partnerships

• Partnership agreement
• Identification documents of the natural persons who are partners Relation
e.g. Certified copy of ID / Passport
• Resolution specifying who is authorized to act on behalf of the
partnership
• Identification document(s) of the person(s) authorized to act on DECLARATION
behalf of the partnership
• Tax clearance certificate
Thereby declare that the details furnished above are true and correct to the best
of my knowledge and belief and I undertake to inform you of any changes therein,
Trusts and Societies immediately. In case any of the above information is found to be false or untrue or
misleading or misrepresenting, I am aware that I may be liable for it.
• Certificate or Registration or other rounding documentation
• Copy of Constitution
• Identification documents for Office Bearers
• Identification documents) of the person(s) authorized to act on Full name
behalf of the society/ church/ club
• Details of Registered Office
• Copy of Resolution authorizing the transaction/ business
relationship Place
• Nature of Business (Where applicable)

D D M M Y Y Y Y
Date
PROMINENT INFLUENTIAL PERSONS SELF
DECLARATION
As Per The Financial Intelligence Act. Any Prominent Influential Signature
Person (PIP) Must Complete The Below Self Declaration.

Prominent Influential Persons (PIPs) are defined as means a person

who is or has been entrusted with public functions within Botswana or
by a foreign country, his or her close associates or immediate member
of the family or an international organization.

The following have been identified to be prominent influential persons

(PIPs). Please tick the relevant box indicating the position you hold.

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PROMINENT INFLUENTIAL PERSONS SELF DECLARATION
As Per The Financial Intelligence Act. Any Prominent Influential Person (PIP) Must Complete The Below Self Declaration.
Prominent Influential Persons (PIPs) are defined as means a person who is or has been entrusted with public functions within Botswana or by a foreign country, his or her
close associates or immediate member of the family or an international organization.

The following have been identified to be prominent influential persons (PIPs). Please tick the relevant box indicating the position you hold.

President

Vice President

Cabinet Minister

Speaker or National Assembly

Debut Speaker of National Assembly

Member of National Assembly

Councillor

Senior Government Official

Judicial Officer

Kgosi

Senior Executive of a Private entity

Senior Executive of a Public Body

Senior Executive of a Political Party

Senior Executives of International Organisations Operating in Botswana, or such person as may be prescribed

PROTECTION OF PERSONAL DATA NOTICE

CLIENT INFORMATION SHARING CONSENT

Botswana Life Insurance Limited (“Botswana Life”) will process and protect your personal information as required by relevant laws in the provision of services. Such
processing may include personal identifiable information as well as financial and relevant health information. You have the right to ask us for a cop of your personal
information and to update or correct. Our complete privacy policy is available on our company website

We collect, process, record, collate, store, analyses, disclose and disseminate personal information for purposes:

y to conclude and administer your account or polices which may include underwriting,
y collection of payments:
y assessing and processing amendments and claims /pay-out ;
y to comply with all legal and regulatory requirements, including applicable prudential rules and codes of conduct in our industry
y to protect the Botswana Life’s interests;
y reinsurance and
y any purposes related to the above.

If you do not provide the requested information, the Botswana Life cannot provide the requested services
By signature hereof, you give consent for sharing of your personal information with Botswana Life Insurance Limited, including its parent company Botswana Insurance
Holdings Limited and its subsidiaries (collectively “the BIHL Group”) in connection with services rendered by the Group and with other service providers where required for
any of the purposes listed above including aw enforcement agencies.

We may send your personal information to service providers outside Botswana for the storage or further processing on the Botswana Life’s behalf. We will ensure we
adhere to the provisions of the Data Protection Act before such trans bonder transfer of your personal information. Botswana Life may provide you with information about
its financial products and other services which may include text messages, emails and other related platforms. If you do not wish to receive such information, you have the
right to withdraw such consent.

Client Consent Declaration

I/We understand that the Botswana Life may hold information gathered about me from the other BIHL Group subsidiaries and as such my rights under the Data
protection Act will not be affected

I/We understand that all my personal information is treated as private and confidential by BLIL staff, independent contractors, agents and volunteers.

I/We understand that personal information is held about me.

I/We have had the opportunity to discuss the implications of sharing or not sharing information about me.

I/We have the right to see any information that Botswana Life holds about me, and to have my details removed.

I/We understand my/our right to privacy and the right to have my/our personal information processed in accordance with the conditions for the lawful processing or
personal information.

I/we consent to share my/our personal information voluntarily and understand that such consent may be withdrawn at any time

I/We agree that personal information about me may be shared and gathered from the following BIHL Group companies (including their subsidiaries):

a. Botswana Insurance Fund Management Limited (BIFM)

b. BIFM Unit Trusts (Pty) Limited (BIFM UT)
c. Botswana life Insurance Limited (BLIL
d. Botswana Insurance Company Limited (BIC)
e. BIHL Insurance Company trading as Legal Guard

Full Names: Capacity

Authorized
Signature D D M M Y Y Y Y
Date

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