Hdfc Ergo Kyc Form Download Pdf

	KYC CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual Important Instructions: A) Fields marked with '*' are mandatory fields. B) Please fill the form in English and in BLOCK letters. C) Please fill the date in DD-MM-YYYY format. D) Please read section wise detailed guidelines / instructions at the end E) List of State / U.T code as per Indian Motor Vehicle Act. 1988 is available at the end. F) List of two character ISO 3166 country codes is available at the end. G) KYC number of applicant is mandatory for update application. H) For particular section update, please tick (ü) in the box available before the section number and strike of the sections not required to be updated. For office use only Application Type* New        Update (To be filled by financial institution) KYC Number (Mandatory for KYC update request) Account Type* Normal    Simplified (for low risk customers)    Small 1. PERSONAL DETAILS (Please refer instuction A at the end) Prefix First Name Middle Names Last Name Name* (Same as ID proof) Maiden Name (if any*) Father / Spouse Name* Mother Name* Date of Birth* — — Gender* M- Male F- Female T- Transgender Marital Status* Married Unmarried Others Citizenship* IN- Indian Others (ISO 3166 Country Code ) Residential Status* Resident Individual Non Resident Indian Foreign National Person of Indian Origin Occupation Type* S-Servics Sector( Private Public Sector Government Sector) O-Others ( Professional Self Employed Retired Housewife Student B-Business X- Not Categorised PHOTO Signature / Thumb Impression 2. TICK IF APPLICABLE RESIDENCE FOR TAX PURPOSES IN JURISDICTION(S) OUTSIDE INDIA (Please refer instuction B at the end) ADDITIONAL DETAILS REQUIRED* (Mandatry only if section 2 is ticked) ISO 3166 Country Code of Jurisdiction of Residence* Tax Identification Number of equivalent (if issued by jurisdiction)* Place / City of Birth* ISO 3166 Country Code of Birth* 3. PROOF OF IDENTITY(Pol)* (Please refer instuction C at the end) (Certified copy of any one of the following Proof of ldentity [Pol] needs to be submitted) A- Passport Number Passport Expiry Date B- Voter ID Card C- PAN Card D- Driving Licence Driving Licence Expiry Date E- UID (Aadhaar) F- NREGA Job Card Z- Others (any document notified by the central government) Identification Number S- Simplified Measures Account - Document Type code Identification Number 4. PROOF OF ADDRESS (PoA)* 4.1 CURRENT / PERMANENT / OVERSEAS ADDRESS DETAILS(Please see instruction D at the end) (Certified copy of any one of the following Proof of Address [PoA] needs to be submitted) Address Type* Residential / Business Residential Business Registered Office Unspecified Proof of Address* Passport Driving Licence UID (Aadhaar) Voter Identity Card NREGA Job Card Others Simplified Measures Account - Document Type code Address Line 1* Line 2* Line 3* District* Pin / Post Code* State / U.T Code* ISO 3166 Country Code* 4.2 CORRESPONDENCE / LOCALADDRESS DETAILS* (Please see instuction E at the end) Same as Current / Permanent / Overseas Address details (In case of multiple correspondence / local addresses, please fill 'Annexure A1') Line 1* Line 2* Line 3* District* Pin / Post Code* State / U.T Code* ISO 3166 Country Code* 4.3 ADDRESS IN THE JURISDICTION DETAILS WHERE APPLICANT IS RESIDENT OUTSIDE INDIA FOR TAX PURPOSES* (Applicable if section 2 is ticked) Same as Current / Permanent / Overseas Address details Same as Correspondence / Local Address details Line 1* Line 2* Line 3* State* ZIP / Post Code* ISO 3166 Country Code* 5. CONTACT DETAILS (All communications will be sent on provided Mobile no. / Email-ID) (Please refer instruction F at the end) Tel. (Off) Tel. (Res) Mobile FAX Email ID 6. DETAILS OF RELATED PERSON (In case of additional related persons, please fill 'Annexure B1') (please refer instruction G at the end) Addition of Related Person Deketion of Related Person KYC Number of Related Person (if available*) Related Person Type* Guardian of Minor Assignee Authorized Representative Prefix First Name Middle Names Last Name Name* (If KYC number and name are provided, below details of section 6 are optinal) PROOF OF IDENTITY [PoI] OF RELATED PERSON* (Please see instruction (H) at the end) A- Passport Number Passport Expiry Date B- Voter ID Card C- PAN Card D- Driving Licence Driving Licence Expiry Date E- UID (Aadhaar) F- NREGA Job Card Z- Others (any document notified by the central government) Identification Number S- Simplified Measures Account - Document Type code Identification Number 7. REMARKS (If any) 8. APPLICANT 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 held liable for it. I hereby consent to receiving information from Central KYC Registry through SMS/Email on the above registered number/email address Date: Place: 9. ATTESTATION / FOR OFFICE USE ONLY Documents Received Certified Copies KYC VERIFICATION CARRIED OUT BY Date : Emp. Name Emp. Code Emp. Designation Emp. Branch

	CENTRAL KYC REGISTRY | Instructions / Check list / Guidelines for filling individual KYC Application Form General Instructions: Fields marked with are mandatory fields. Tick '✓' wherever applicable. Self-Certification of documents is mandatory. Please fill the form in English and in BLOCK Letters. Please fill all dates in DD-MM-YYYYformat. Wherever state code and country code is to be furnished, the same should be the two-digit code as per Indian Motor Vehicle, 1988 and ISO 3166 country code respectively list of which is available at the end. KYC number of applicant is mandatory for updation of KYC details. For particular section update, please tick (✓) in the box available before the section number and strike off the sections not required to be updated. In case of 'Small Account type' only personal details at section number 1 and 2, photograph, signature and self-certification required. A Clarification / Guidelines on filling 'Personal Details'section Name: Please state the name with Prefix (Mr/Mrs/Ms/Dr/etc.). The name should match the name as mentioned in the Proof of Identity submitted failing which the application is liable to be rejected. Either father's name or spouse's name is to be mandatorily furnished. In case PAN is not available father's name is mandatory. B Clarification / Guidelines on filling details if applicant residence for tax purposes in jurisdiction(s) outside India Tax identification Number (TIN): TIN need not be reported if it has not been issued by the jurisdiction. However, if the said jurisdiction has issued a high integrity number with an equivalent level of identification (a "Functional equivalent"), the same may be reported. Examples of that type of number for individual include, a social security/insurance number, citizen/personal identification/services code/number, and resident registration number) C Clarification / Guidelines on filling 'Proof of Identity [Pol]' section If driving license number or passport is provided as proof of identity then expiry date is to be mandatorily furnished. Mentio identification / reference number if 'Z- Others (any document notified by the central government)' is ticked. In case of Simplified Measures Accounts for verifying the identity of the applicant, any one of the following documents can also be submitted and undernoted relevant code may be mentioned in point 3 (S). Document Code Description 01 Identity card with applicant's photograph issued by Central / State Government Departments, Statutory / Regulatory Authorities, Public Sector Undertakings, Scheduled Commercial Banks, and Public Financial Institutions. 02 Letter issued by a gazetted officer, with a duly attested photograph of the person. D Clarification / Guidelines on filling 'Proof of Address (PoA) - Current / Permanent / Overseas Address details' section PoA to be submitted only if the submitted Pol does not have an address or address as per Pol is invalid or not in force. State / U.T Code and Pin / Post Code will not be mandatory for Overseas addresses. In case of Simplified Measures Accounts for verifying the address of the applicant, any one of the following documents can also be submitted and undernoted relevant code may be mentioned in point 4.1. Document Code Description 01 Utility bill which is not more than two months old of any service provider (electricity, telephone, post-paid mobile phone, piped gas, water bill). 02 Property or Municipal Tax receipt. 03 Bank account or Post Office savings bank account statement. 04 Pension or family pension payment orders (PPOs) issued to retired employees by Government Departments or Public Sector Undertakings, if they contain the address. 05 Letter of allotment of accommodation from employer issued by State or Central Government departments, statutory or regulatory bodies, public sector undertakings, scheduled commercial banks, financial institutions and listed companies. Similarly, leave and license agreements with such employers allotting official accommodation. 06 Documents issued by Government departments of foreign jurisdictions and letter issued by Foreign Embassy or Mission in India. E Clarification / Guidelines on filling 'Proof of Address [PoA] - Correspondence / Local Address details' section To be filled only in case the PoA is not the local address or address where the customer is currently residing. No separate PoA is required to be submitted. In case of multiple correspondence / local addresses. Please fill 'Annexure Al' F Clarification / Guidelines on filling 'Contact details' section Please mention two- digit country code and 10 digit mobile number (e.g. for Indian mobile number mention 91-9999999999). Do not add '0' in the beginning of Mobile number. G Clarification / Guidelines on filling 'Related Person details' section Provide KYC number of related person if available. H Clarification / Guidelines on filling 'Related Person details - Proof of Identity [Pol] of Related Person' section Mention identification / reference number if Z- Others (any document notified by the central government)' is ticked.

	List of two - digit state / U.T codes as per Indian Motor Vehicle Act, 1988 State / U.T Code Andaman & Nicobar AN Andhra Pradesh AP Arunachal Pradesh AR Assam AS Bihar BR Chandigarh CH Chattisgarh CG Dadra and Nagar Haveli DN Daman & Diu DD Delhi DL Goa GA Gujarati GJ Haryana HR State / U.T Code Himachal Pradesh HP Jammu & Kashmir JK Jharkhand JH Karnataka KA Kerala KL Lakshadweep LD Madhya Pradesh MP Maharashtra MH Manipur MN Meghalaya ML Meghalaya MZ Nagaland NL Orissa OR State / U.T Code Pondicherry PY Punjab PB Rajasthan RJ Sikkim SK Tamil Nadu TN Telangana TS Tripura TP Uttar Pradesh UP Uttarakhand UA West Bengal WB Other XX List of ISO 3166 two- digit Country Code Country Country Code Afghanistan AF Aland Islands AX Albania Al Algeria DZ American Samoa AS Andorra AD Angola AO Anguilla AL AntarcticaAntarctica AQ Antigua and Barbuda AG Argentina AR Armenia AM Aruba AQ Australia AU Austria AT Azerbaijan AZ Bahamas BS Bahrain BH Bangladesh BD Barbados BB Belarus BY Belgium BE Belize BE Benin BJ Bermuda BM Bhutan BT Bolivia, Plurinational State of BO Bonaire, Sint Eustatius and Saba BQ Bosnia and Herzegovina BA Botswana BW Bouvet Island BV Brazil BR British Indian Ocean Territory IO Brunei Darussalam BN Bulgaria BG Burkina Faso BF Burundi BI Cabo Verde CV Cambodia KH Cameroon CM Canada CA Cayman Islands KY Central African Republic CF Chad TO Chile CL China CN Christmas Island CX Cocos (Keeling) Islands CC Colombia CO Comoros KM Congo CG Congo, the Democratic Republic of the CD Cook Islands CK Costa Rica CR Cote d'Ivoire ICfite d'Ivoire CI Croatia HR Cuba CU Curacao ICurafao CW Cyprus CY Czech Republic CZ Denmark DK Djibouti DJ Dominica DM Country Country Code Dominican Republic DO Ecuador EC Egypt EG El Salvador SV Equatorial Guinea GQ Eritrea ER Estonia EE Ethiopia ET Falkland Islands (Malvinas) FK Faroe Islands FO Fiji FJ Finland FI France FR French Guiana GF French Polynesia PF French Southern Territories TF Gabon GA Gambia GM Georgia GE Germany DE Ghana GH Gibraltar GI Greece GR Greenland GL Grenada GD Guadeloupe GP Guam GU Guatemala GT Guermsey GG Guinea GN Guinea-Bissau GW Guyana GY Halti GT Heard Island and McDonald Islands HM Holy See (Vatican City State) VA Honduras HN Hong Kong HK Hungary HU Iceland IS India IN Indonesia ID Iran, Islamic Republic of IR Iraq IQ Ireland IE Isle of Man IM Israel IL Italy IT Jamaica JM Japan JP Jersy JE Jordan JO Kazakhstan KZ Kenya KE kiribati KI Korea, Democratic People's Republic of KP Korea, Republic of KR Kuwait KW Kyrgyzstan KG Lao People's Democratic Republic LA Latvia LV Lebanon LB Lesotho LS Liberia LR Country Country Code Libya LY Liechtenstein LI Lithuania LT Luxembourg LU Macao MO Macedonia, the former Yugoslav Republic of MK Madagascar MG Malawi MW Malaysia MY Maldives MV Mali ML Malta MT Marshall Islands MH Martinique MQ Mauritania MR Mauritius MU Mayotte YT Mexico MX Micronesia, Federated States of FM Moldova, Republic of MD Monaco MC Mongolia MN Montenegro ME Montserrat MS Morocco MA Mozambique MZ Myanmar MM Namibia NA Nauru NR Nepal NP Netheriands NL New Claedonia NC New Zealand NZ Nicaragua NI Niger NE Nigeria NG Niue NU Norfolk Island NF Northern Mariana Islands MP Norway NO Oman OM Pakistan PK Palau PW Palestine, State of PS Panama PA Papua New Guinea PG Paraguay PY Peru PE Philippines PH Pitcairn PN Poland PL Portugal PT Puerto Rica PR Qatar QA Reunioun IReuioun RE Romania RO Russian Federation RU Rwanda RW Saint Barthelemy ISaint Barthelemy BL Saint Helena, Ascension and Tristan da Cunha SH Saint Kitts and Nevls KN Saint Lucia LC Sain Martin (French part) MF Country Country Code Saint Plerre and Miquelon PM Saint vincent and the Grenadines VC Samoa WS San Marino SM Sao Tome and Principe ST Saudi Arabia SA Senegal SN Serbia RS Seychelles SC Slerra Leone SL Singapore SG Sint Maarten (Dutch part) SX Slovakia SK Slovenia SI Solomon Islands SB Somalia SO South Africa ZA Southe Georgia and the South Sandwich Islands GS South Sudan SS Spain ES Sri Lanka LK Sudan SD Suriname SR Svalbard and Jan Mayen SJ Swaziland SZ Swedan SE Switzerland CH Syrian Arab Republic SY Taiiwan, Province of China TW Tajikistan TJ Tanzania, United Republic of TZ Tahiland TH Timor -Leste TL Togo TG Tokelau TK Tonga TO Trinidad and Tobago TT Tunisia TN Turkey TR Turkmenistan TM Turks and Caicos islands TC Tuvalu TV Uganda UG Ukraine UA United Arab Emirates AE United Kingdom GB United States US United States Minor Outlying Islands UM Uruguay UY Uzbekistan UZ Vanuatu VU Venezuela, Bolivarian Republic of VE Viet Nam VN Virgin Islands, British VG Virgin Islands, U.S. VI Walls and Futana WF Western Sahara EH Yemen YE Zambia ZM Zimbabwe ZW

	Annexure A1 CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual | Correspondence / Local Address Important Instructions: A) Fields marked with '*' are mandatory fields. B) Please fill the form in English and in BLOCK letters. C) Please fill the date in DD-MM-YYYY format. D) Please read section wise detailed guidelines / instructions at the end E) List of State / U.T code as per Indian Motor Vehicle Act. 1988 is available at the end. F) List of two character ISO 3166 country codes is available at the end. G) KYC number of applicant is mandatory for update application. H) For particular section update, please tick (ü) in the box available before the section number and strike of the sections not required to be updated. For office use only Application Type* New    Update (To be filled by financial institution) KYC Number (Mandatory for KYC update request) 1. CORRESPONDENCE / LOCALADDRESS DETAILS (Please see instuction E at the end) Same as Current / Permanent / Overseas Address details Line 1* Line 2* Line 3* District* Pin / Post Code* State / U.T Code* ISO 3166 Country Code* 2. CONTACT DETAILS (All communications will be sent on provided Mobile no./Email.ID) (Please refer instruction F at the end) Tel. (Off) Tel. (Res) Mobile FAX Email ID 3. APPLICANT 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 held liable for it. Date: Place:

	Annexure B1 CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual | Related Person Important Instructions: A) Fields marked with '*' are mandatory fields. B) Please fill the form in English and in BLOCK letters. C) Please fill the date in DD-MM-YYYY format. D) Please read section wise detailed guidelines / instructions at the end E) List of State / U.T code as per Indian Motor Vehicle Act. 1988 is available at the end. F) List of two character ISO 3166 country codes is available at the end. G) KYC number of applicant is mandatory for update application. H) For particular section update, please tick (ü) in the box available before the section number and strike of the sections not required to be updated. For office use only Application Type* New    Update (To be filled by financial institution) KYC Number (Mandatory for KYC update request) 1. DETAILS OF RELATED PERSON (In case of additional related persons, please fill 'Annexure B1') (please refer instruction G at the end) Addition of Related Person Deletion of Related Person KYC Number of Related Person (if available*) Related Person Type* Guardian of Minor Assignee Authorized Representative Prefix First Name Middle Names Last Name Name* (If KYC number and name are provided, below details of section 6 are optinal) PROOF OF IDENTITY (POI) OF RELATED PERSON* (Please see instruction (H) at the end) A- Passport Number Passport Expiry Date B- Voter ID Card C- PAN Card D- Driving Licence Driving Licence Expiry Date E- UID (Aadhaar) F- NREGA Job Card Z- Others (any document notified by the central government) Identification Number S- Simplified Measures Account - Document Type code Identification Number 2. APPLICANT 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 held liable for it. Date: Place: [Signature / Thumb Impression] Signature / Thumb Impression of Applicant 3. ATTESTATION / FOR OFFICE USE ONLY Documents Received Certified Copies KYC VERIFICATION CARRIED OUT BY Date : Emp. Name Emp. Code Emp. Designation Emp. Branch

HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&TGeneral Insurance Company Limited upto Sept 13, 2016). CIN: U66030MH2007PLC177117. Registered & Corporate Office: st1Floor, HDFC House, 165 - 166 Backbay Reclamation, H. T. Parekh Marg, Churchgate, Mumbai – 400 020. Customer Service Address: D-301, 3rd Floor, Eastern Business District (Magnet Mall), LBS Marg, Bhandup (West), Mumbai - 400 078. For more details on the risk factors, terms and conditions, please read the sales brochure before concluding the sale. Trade Logo of HDFC ERGO General Insurance Company Ltd. displayed above belongs to HDFC LTD and ERGO International AG and used by HDFC ERGO General Insurance Company under license. Toll-free: 1800 2 700 700 | Fax: 91 22 66383699 | care@hdfcergo.com | www.hdfcergo.com.UIN:HDFHLIP10002V010910. IRDAI Reg No. 146.

Source: https://customersupport.hdfcergo.com/DigitalClaimForms/KYC-form-english_ctc.aspx

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