KNOW YOUR CUSTOMER FORM

NON-MEXICAN INDIVIDUAL

*Date Received
DAY MONTH YEAR

*Location: Office Home Other *Required

*Mexican tax id (with suffix code) or

*Date of birth *Country of birth
Immigration document No. or Passport No.
*State of birth
*Occupation or Profession *Nationality
(place)

*Customer Name
Given Name(s) Paternal Surname Maternal Surname

Home
*Address
Mailing
Street No. Apt. No.

Colonia or Development District or City State Zip/Postal Code

*Profession *Type of Business *Place of Residence Email

*Mexican identity code (CURP) Electronic Signature Serial Number (FIEL),

*Mobile No. *Phone (Home/Office)
or equivalent

Do you currently hold or have you held public Year(s) in office

YES NO Office held
office? (PEP: Personally Exposed Person)

Do you have a partner or relative who is a politically exposed person? YES NO Relationship

RESOURCE PROVIDER (RP)

If this operation is being conducted via a third party, Is this a politically exposed person (PEP)?
provide the following information: YES NO

Name
Given Name(s) Paternal Surname Maternal Surname

Country of birth State of birth (place)

Date of birth Relationship Nationality

Home address
Street No. Apt. No.

Colonia or Development District or City State Zip/Postal Code

Occupation Profession Type of Business Email

Mexican Tax Id (RFC) or Electronic Signature Serial Number (FIEL),

Mobile Phone (Home/Office)
equivalent

Mexican Identity Code (CURP) or equivalent

"Resource Provider, the person who, without being the Customer on an Operation with an investment saving component, provides the resources without obtaining
the financial benefits resulting from the Operation."
 BENEFICIARY

Name
Given Name(s) Paternal Surname Maternal Surname

Country of birth State of birth (place)

Date of birth Relationship Nationality

Address
Street No. Apt. No.

Colonia or Development District or City State Zip/Postal Code

Occupation Profession Type of Business Email

Mexican Tax Id (RFC) or Electronic Signature Serial Number (FIEL),

Mobile Phone (Home/Office)
equivalent

Mexican Identity Code (CURP) or equivalent

ATTACH THE FOLLOWING DOCUMENTS TO THIS APPLICATION (VERIFIED COPIES)

Insured or
LEGIBLE & VALID RP Beneficiary
Contracting Party
Immigration document
Mexican Identity Code (CURP) and/or Tax
Identification Card (equivalent)
Valid government-issued id (both sides) Passport, Professional License, Military Id
Proof of address (dated no more than 3 months
Power, Water or Phone Bill, Bank Statement
prior)
Advanced Electronic Signature registry certificate

AGENT:
I affirm that prior to signing the contract, I, the insurance agent, personally met with the customer or their representative to collect the respective
information and identifications, and also that the information noted on this form is true and accurate, and that the documents the customer provided to
me were checked against the originals, in accordance with Art. 492 of the Mexican Insurance and Surety Bond Company Law (Ley de Instituciones de
Seguros y de Fianzas), which Seguros Atlas, S.A. may corroborate as deemed necessary.

CUSTOMER/CONTRACTING PARTY:
I affirm that prior to signing the contract, I, the customer/contracting party (or representative) personally met with the insurance agent and that the
information noted in this document is true and accurate, and that the documents provided are true to their originals, which Seguros Atlas, S.A. may
corroborate at their discretion.

CONSENT
In accordance with the Mexican Data Protection Law (Ley Federal de Protección de Datos Personales en Posesión de los Particulares), I hereby authorize
Seguros Atlas, S.A. to treat and, where necessary, share my personal, sensitive and financial information for all purposes related to our legal relationship and
also for those purposes outlined in the Privacy Notice, the content of which is known to me having been provided to me in advance.
If I have provided personal, sensitive or financial information for another person, I acknowledge my obligation to inform such other persons that I have
provided their information to Seguros Atlas, S.A. and to inform them of where they can consult the Privacy Notice in reference.

CUSTOMER NAME AND SIGNATURE INSURANCE AGENT NAME AND SIGNATURE

(REQUIRED) (REQUIRED)

PRIVACY NOTICE
In compliance with the Mexican Data Protection Law, Seguros Atlas, S.A. (Seguros Atlas) with address at Paseo de los Tamarindos No. 60-PB, Col. Bosques de las
Lomas, 05120 México, D.F. Ph.: (55)9177-50-00, informs you that the general and sensitive personal information you have provided will be treated to assess your
application for insurance and risk selection, and as such is the case, to draft the insurance contract, process claims payments, for the administration, maintenance
and renewal of the insurance policy, the prevention of fraud and illicit transactions, for statistical purposes, and for all purposes related to the fulfillment of our
obligations, as required by the contract, the Mexican Insurance Contract Law (Ley sobre el Contrato de Seguro) and other applicable legislation.
For more information, visit our website www.segurosatlas.com.mx where you will find our complete Privacy Notice and the mechanisms for exercising
your personal data rights ('ARCO').