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Customer Information Form

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اahmed Amer
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28 views2 pages

Customer Information Form

Uploaded by

اahmed Amer
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Customer Information Form

2020

Explanation:

Insurers are not allowed to offer insurance cover that is contrary to the applicable laws and regulations. Under the anti-terrorism
and Sanction Regulations, MS Amlin is required to check whether a company, its directors and legal representatives, and
ultimate beneficial owners (UBO) are named on the (EU, UK, UN and the like) Sanction List s.

In this declaration, Ultimate Beneficial Owner (UBO) denotes any natural person who - directly or indirectly - has an interest in
an organisation or that organisation’s assets, which includes: capital interest, voting rights, effective control and the right to
receive a payment from the assets or special control over those assets.

For the purpose of our customer due diligence process, please fill in the form below.

1. Company details

Name according to the


Articles of Association
Trading name

Legal form

Full address details


statutory seat:

Place of establishment

Company Registration
Number and full contact
details of the Register

Please provide details of the directors:


Surname and first name Nationality Place of domicile Date of birth Also UBO
1
2
3
4
5
6
7

MS Amlin Marine N.V. (Dutch Branch) | Beursplein 37, ROTTERDAM | P.O. Box 30152 | 3001 DD Rotterdam | Tel +31 10 799 5800 |
www.msamlin.com
MS Amlin Marine N.V. is licensed and regulated by the Financial Services Markets Authority (FSMA) as underwriting agent with registration no
0670.726.393
Registered in the Dutch Chamber of Commerce under 24448058
ABN AMRO Bank N.V., Amsterdam, beneficiary: MS Amlin Marine N.V., IBAN NL34ABNA0240349555 Swift code ABNANL2A
Registered adress: Boulevard du Roi Albert – II 37, 1030, Schaerbeek, Brussels, Belgium
2. UBO Declaration

We do not have any Ultimate Beneficial Owners with an interest of 50% or more;

OR

We have Ultimate Beneficial Owners with an interest of 50% or more (capital, voting rights):

% Capital interest,
Surname and first name Place of (in)direct voting right or
(natural persons only) Nationality domicile Date of birth interest effective control
1
2
3

3. Information
We will notify MS Amlin as soon as possible if:

 the number of Ultimate Beneficial Owners with an interest of 50% or more changes, supplying the
details requested above for the beneficial owner(s) concerned;
 the details of an Ultimate Beneficial Owner with an interest of 50% or more change.

4. Signature

The person(s) signing this declaration is/are authorised to confirm the client information above,
including the identity of the Directors and UBO’s listed above and to sign this Declaration on behalf of
the company.

Place date
Name(s) of
undersigned
Position
Signature(s)

5. Data Protection
The data as submitted above is collected and stored in MS Amlin central systems in accordance
with European data protection regulations for the sole purpose of MS Amlin’s Customer Due
Diligence process. The full Data Privacy Notice can be found on www.msamlin.com/en/site-
services/data-privacy-notice.html. A paper copy of the Data Privacy Notice can be obtained by
contacting the Data Protection Officer by email (dataprotectionofficer@msamlin.com) or at the
below address:

Data Protection Officer; MS Amlin plc; The Leadenhall Building; 122 Leadenhall Street;
London EC3V 4AG.
MS Amlin Marine N.V. (Dutch Branch) | Beursplein 37, ROTTERDAM | P.O. Box 30152 | 3001 DD Rotterdam | Tel +31 10 799 5800 |
www.msamlin.com
MS Amlin Marine N.V. is licensed and regulated by the Financial Services Markets Authority (FSMA) as underwriting agent with registration no
0670.726.393
Registered in the Dutch Chamber of Commerce under 24448058
ABN AMRO Bank N.V., Amsterdam, beneficiary: MS Amlin Marine N.V., IBAN NL34ABNA0240349555 Swift code ABNANL2A
Registered adress: Boulevard du Roi Albert – II 37, 1030, Schaerbeek, Brussels, Belgium

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