KNOW YOUR CUSTOMER: INDIVIDUALS

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

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Form last completed in M M Y Y Y Y Policy Number

SECTION A: IDENTITY DETAILS

Title

Name (s) Su r n a m e

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 M o bil e

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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ANTI - MONEY LAUNDERING AND COUNTER TERRORIST FINANCING REQUIREMENTS

In accordance with the Financial Intelligence Regulations, the following documents should be provided for verification:

Natural Persons
1. Identification document within 6 months validity i.e Certified Omang for citizens; Certified Passport including work and
residence permit or exemption for foreign nationals; Certified Refugee Identity Card for refugees
2. Proof of source of funds/income i.e. payslip (not older than 3 months); recent 3 months bank statements; letter from
employer(not older than 3 months).
3. Proof of residence i.e. utility bill (not older than 6 months); valid lease agreement (within lease period); letter from
employer (not older than 3 months); letter from Tribal Authority; Affidavit from Commissioner of Oaths; Title Deed;
Council rates receipt
4. Certified Birth Certificate for policies taken out under the name of a minor child.

Companies
• Certification of incorporation
• Memorandum and Articles of Association / Constitution
• Notice of Registered Office and Postal Address
• Identification documents of the person(s) managing the company
• Resolution specifying who is authorised to act on behalf of company
• Identification document(s) of the person(s) authorised to act on behalf of the company
• Shareholder certificate
• Tax clearance certificate
• Details of registered office and place of business

Partnerships
• Partnership agreement
• Identification documents of the natural persons who are partners e.g. Certified copy of ID / Passport
• Resolution specifying who is authorised to act on behalf of the partnership
• Identification document(s) of the person(s) authorised to act on behalf of the partnership
• Tax clearance certificate

Trusts and Societies

• Certificate of Registration or other founding documentation
• Copy of Constitution
• Identification documents for Office Bearers
• Identification document(s) of the person(s) authorised to act on behalf of the society/ church/ club
• Details of Registered Office
• Copy of Resolution authorising the transaction/ business relationship
• Nature of Business (Where applicable)

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.

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PROMINENT INFLUENTIAL PERSONS SELF DECLARATION (continued)

President Kgosi

Vice President Senior Executive of a Private entity

Cabinet Minister Senior Executive of a Public Body

Speaker of National Assembly Senior Executive of a Political Party

Deputy Speaker of National Assembly Senior Executives of International Organisations

Member of National Assembly Operating in Botswana; or such person as may be

Councillor prescribed.

Senior Government Official

Judicial Officer

PIP IN YOUR IMMEDIATE FAMILY OR CLOSE ASSOCIATES

This includes all people that have been entrusted with prominent public function or an individual who is a close associate or
immediate family member to that person.

Full name Title

Address Relation

DECLARATION
I hereby 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, 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.

Full Name Date D D M M Y Y Y Y

Place Signature

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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 copy 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, analyse, disclose and disseminate personal information for purposes:
• to conclude and administer your account or policy(ies) which may include underwriting;
• collection of payments;
• assessing and processing amendments and claims/pay-outs;
• to comply with all legal and regulatory requirements, including applicable prudential rules and codes of conduct in our
industry
• to protect the Botswana Life’s interests;
• reinsurance; and
• 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 law 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 transborder
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 of 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
f) Botswana Life Insurance Holdings Limited - BIHL

Full Names: Capacity:

Authorised
D D M M Y Y Y Y
Signature: Date:

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