Know Your Consultant Addendum

Instructions: 1. Details required to be provided are of the financial consultant 2. All points are mandatory 3. Any cancellation or overwriting needs to be countersigned by the financial consultant

Candidate Id: _________________ Details: a. b. Name: _______________________________________________________ Father/Spouse Name: ___________________________________________

Affix photograph Photograph to be signed across by the financial consultant

1. Name and Address of place of work: _____________________________________________________________________ _____________________________________________________________________ City ________________ State __________________ Pin Code __________________ Tel No: _____ - ____________ Fax No: ____ - __________ Email: _________________________ 2. Proof of Identity: Document submitted for Identity Proof: Name of Issuing Authority: Serial No.: 3. Proof of Residence: Document submitted for Residence Proof: 4. Permanent Account Number (PAN) available: (Please Yes PAN No.: _____________________ No ) Applied For

Date of Issue of Document:

Note: If identity proof is more than 3 years old, a latest photograph of the Proposer should also be affixed on the space above.

5. Main Occupation (Please ): Insurance Agency Salaried

Self Employed/Business

Unemployed

Housewife

Others

6. Nature of occupation (e.g. Financial Advisor, Garment dealer, etc) ______________________________________________________________________________ 7. Industry to which your company or business belongs (e.g. Insurance, Textiles, Cement etc) ______________________________________________________________________________

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Know Your Consultant Addendum

8. Are you a Politically Exposed Person? Definition of a Politically Exposed Person:
A "Politically Exposed Person" is a person who performs important functions for the state. This would include individuals who have or have had positions of public trust such as government officials, senior executives of government corporations, politicians, important political party officials, member of parliament, member of legislative assembly, etc. and their families and close associates.

Please answer Yes or No:

_______

DECLARATIONS:
I hereby declare that: I will provide information as and when required by the company, acting on its own or under any order or instruction received from Statutory Authorities, as regards utilizations or withdrawals of my commissions. I agree to the Company providing any information related to me as available to the Company at any time, to any Statutory Authority in relation to the laws governing prevention of money laundering, applicable in the country. I understand that the Company classifies its Financial Consultants under various categories of risk for the purposes of complying with the laws governing prevention of money laundering and I confirm that I do not have any objections for the same. I understand that the Company has the right to peruse my financial profile and also agree that the Company has right to cancel the Insurance license in case I have been found guilty of any violation of the provisions of any Law, directly or indirectly, having relation to the laws governing prevention of money laundering in the country, by any competent court of law.

Dated: ________________ Place: _________________ Signature of Financial consultant_________________________

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