HDFC ERGO General Insurance Company Limited: Know Your Customer (Kyc) Application Form

HDFC ERGO General Insurance Company Limited
KNOW YOUR CUSTOMER (KYC) APPLICATION FORM
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual
Important Instructions:
A) Fields marked with '*' are mandatory fields. E) List of State / U.T code as per Indian Motor Vehicle Act. 1988 is available
at the end.
B) Please fill the form in English and in BLOCK letters. F) List of two character ISO 3166 country codes is available at the end.
C) Please fill the date in DD-MM-YYYY format. G) KYC number of applicant is mandatory for update application.
D) Please read section wise detailed guidelines / instructions at H) For particular section update, please tick in the box available before the
the end 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) Adesh sharma
Maiden Name (if any*)
Father / Spouse Name* deepak sharma
Mother Name*
Date of Birth* 19 -- 03 -- 1994 PHOTO

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 ( Private Public Government Sector) Signature / Thumb
Sector Sector Impression
O-Others ( Professional Self Retired Housewife Student)
Employed
B-Business
X- Not Categorised
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*
HDFC ERGO General Insurance Company Limited. (Formerly HDFC General Insurance Limited from Sept 14, 2016 and L&T General Insurance Company Limited upto Sept 13, 2016). CIN : U66030MH2007PLC177117.
Registered & Corporate Office: 1st Floor, 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 |
[email protected] | www.hdfcergo.com. IRDAI Reg No. 146. 1
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) 461519634068

F- NREGA Job Card
Z- Others (any document notified Identification Number
by the central government)
S- Simplified Measures Account - Identification Number
Document Type code
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* s/o deepak sharma
Line 2* block B , brahmanand dham educational campus
Line 3* junagadh visavadar City / Town / Village*
highway ,chaparda visavadar
District* Pin / Post Code* 36212 State / U.T Code* ISO 3166 Country Code*
junagadh 0 GJ IN
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')
Address
Line 1*
Line 2*
Line 3* City / Town / Village*
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
Address
Line 1*
Line 2*
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 8449313170
FAX Email ID [email protected]
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 Deletion of Related Person KYC Number of Related Person (if available*)
Related Person Type* Guardian of Minor Assignee Authorized Representative

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)
B- Voter ID Card
C- PAN Card
E- UID (Aadhaar)
F- NREGA Job Card
Document Type code
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: 31/7/2020 Place : CHAPARDA Signature / Thumb Impression of Applicant
9. ATTESTATION / FOR OFFICE USE ONLY
Documents Received Certified Copies
KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS

Date : Name
Emp. Name Code
Emp. Code
Emp. Designation
Emp. Branch
CENTRAL KYC REGISTRY | Instructions / Check list / Guidelines for filling individual KYC Application Form
General Instructions:
1 Fields marked with are mandatory fields.
2 Tick wherever applicable.
3 Self-Certification of documents is mandatory.
4 Please fill the form in English and in BLOCK Letters.
5 Please fill all dates in DD-MM-YYYY format.
6 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.
7 KYC number of applicant is mandatory for updation of KYC details.
8 For particular section update, please tick in the box available before the section number and strike off the sections not required to be updated.
9 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
1 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.
2 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
1 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
1 If driving license number or passport is provided as proof of identity then expiry date is to be mandatorily furnished.
2 Mention identification / reference number if 'Z- Others (any document notified by the central government)' is ticked.
3 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
1 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.
2 State / U.T Code and Pin / Post Code will not be mandatory for Overseas addresses.
3 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
1 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.
2 In case of multiple correspondence / local addresses. Please fill 'Annexure Al’
F Clarification / Guidelines on filling 'Contact details' section
1 Please mention two- digit country code and 10 digit mobile number (e.g. for Indian mobile number mention 91-9999999999).
2 Do not add '0' in the beginning of Mobile number.
G Clarification / Guidelines on filling 'Related Person details' section
1 Provide KYC number of related person if available.
H Clarification / Guidelines on filling 'Related Person details - Proof of Identity [Pol] of Related Person' section
1 Provide KYC number of related person if available.
List of two - digit state / U.T codes as per Indian Motor Vehicle Act, 1988
State / U.T Code State / U.T Code State / U.T Code
Andaman & Nicobar AN Himachal Pradesh HP Pondicherry PY
Andhra Pradesh AP Jammu & Kashmir JK Punjab PB
Arunachal Pradesh AR Jharkhand JH Rajasthan RJ
Assam AS Karnataka KA Sikkim SK
Bihar BR Kerala KL Tamil Nadu TN
Chandigarh CH Lakshadweep LD Telangana TS
Chattisgarh CG Madhya Pradesh MP Tripura TR
Dadra and Nagar Haveli DN Maharashtra MH Uttar Pradesh UP
Daman & Diu DD Manipur MN Uttarakhand UA
Delhi DL Meghalaya ML West Bengal WB
Goa GA Mizoram MZ Other XX
Gujarati GJ Nagaland NL
Haryana HR Orissa OR
List of ISO 3166 two- digit Country Code

Country Country Country Country Country Country Country Country
Code Code Code Code
Afghanistan AF Dominican Republic DO Libya LY Saint Plerre and Miquelon PM
Aland Islands AX Ecuador EC Liechtenstein LI Saint vincent and the Grenadines VC
Albania Al Egypt EG Lithuania LT Samoa WS
Algeria DZ El Salvador SV Luxembourg LU San Marino SM
American Samoa AS Equatorial Guinea GQ Macao MO Sao Tome and Principe ST
Andorra AD Eritrea ER Macedonia, the former Yugoslav MK Saudi Arabia SA
Republic of
Angola AO Estonia EE Madagascar MG Senegal SN
Anguilla AL Ethiopia ET Malawi MW Serbia RS
AntarcticaAntarctica AQ Falkland Islands (Malvinas) FK Malaysia MY Seychelles SC
Antigua and Barbuda AG Faroe Islands FO Maldives MV Slerra Leone SL
Argentina AR Fiji FJ Mali ML Singapore SG
Armenia AM Finland FI Malta MT Sint Maarten (Dutch part) SX
Aruba AQ France FR Marshall Islands MH Slovakia SK
Australia AU French Guiana GF Martinique MQ Slovenia SI
Austria AT French Polynesia PF Mauritania MR Solomon Islands SB
Azerbaijan AZ French Southern Territories TF Mauritius MU Somalia SO
Bahamas BS Gabon GA Mayotte YT South Africa ZA
Bahrain BH Gambia GM Mexico MX Southe Georgia and the South GS
Sandwich Islands
Bangladesh BD Georgia GE Micronesia, Federated States of FM South Sudan SS
Barbados BB Germany DE Moldova, Republic of MD Spain ES
Belarus BY Ghana GH Monaco MC Sri Lanka LK
Belgium BE Gibraltar GI Mongolia MN Sudan SD
Belize BE Greece GR Montenegro ME Suriname SR
Benin BJ Greenland GL Montserrat MS Svalbard and Jan Mayen SJ
Bermuda BM Grenada GD Morocco MA Swaziland SZ
Bhutan BT Guadeloupe GP Mozambique MZ Swedan SE
Bolivia, Plurinational State of BO Guam GU Myanmar MM Switzerland CH
Bonaire, Sint Eustatius and Saba BQ Guatemala GT Namibia NA Syrian Arab Republic SY
Bosnia and Herzegovina BA Guermsey GG Nauru NR Taiiwan, Province of China TW
Botswana BW Guinea GN Nepal NP Tajikistan TJ
Bouvet Island BV Guinea-Bissau GW Netheriands NL Tanzania, United Republic of TZ
Brazil BR Guyana GY New Claedonia NC Tahiland TH
British Indian Ocean Territory IO Halti GT New Zealand NZ Timor -Leste TL
Brunei Darussalam BN Heard Island and McDonald HM Nicaragua NI Togo TG
Islands
Bulgaria BG Holy See (Vatican City State) VA Niger NE Tokelau TK
Burkina Faso BF Honduras HN Nigeria NG Tonga TO
Burundi BI Hong Kong HK Niue NU Trinidad and Tobago TT
Cabo Verde CV Hungary HU Norfolk Island NF Tunisia TN
Cambodia KH Iceland IS Northern Mariana Islands MP Turkey TR
Cameroon CM India IN Norway NO Turkmenistan TM
Canada CA Indonesia ID Oman OM Turks and Caicos islands TC
Cayman Islands KY Iran, Islamic Republic of IR Pakistan PK Tuvalu TV
Central African Republic CF Iraq IQ Palau PW Uganda UG
Chad TO Ireland IE Palestine, State of PS Ukraine UA
Chile CL Isle of Man IM Panama PA United Arab Emirates AE
China CN Israel IL Papua New Guinea PG United Kingdom GB
Christmas Island CX Italy IT Paraguay PY United States US
Cocos (Keeling) Islands CC Jamaica JM Peru PE United States Minor Outlying UM
Islands
Colombia CO Japan JP Philippines PH Uruguay UY
Comoros KM Jersy JE Pitcairn PN Uzbekistan UZ
Congo CG Jordan JO Poland PL Vanuatu VU
Congo, the Democratic Republic CD Kazakhstan KZ Portugal PT Venezuela, Bolivarian Republic of VE
of the
Cook Islands CK Kenya KE Puerto Rica PR Viet Nam VN
Costa Rica CR kiribati KI Qatar QA Virgin Islands, British VG
Cote d'Ivoire ICfite d'Ivoire CI Korea, Democratic People's KP Reunioun IReuioun RE Virgin Islands, U.S. VI
Republic of
Croatia HR Korea, Republic of KR Romania RO Walls and Futana WF
Cuba CU Kuwait KW Russian Federation RU Western Sahara EH
Curacao ICurafao CW Kyrgyzstan KG Rwanda RW Yemen YE
Cyprus CY Lao People's Democratic LA Saint Barthelemy ISaint BL Zambia ZM
Republic Barthelemy
Czech Republic CZ Latvia LV Saint Helena, Ascension and SH Zimbabwe ZW
Tristan da Cunha
Denmark DK Lebanon LB Saint Kitts and Nevls KN
Djibouti DJ Lesotho LS Saint Lucia LC
Dominica DM Liberia LR Sain Martin (French part) MF
Annexure A1
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual | Correspondence / Local Address
at the end.

1. CORRESPONDENCE / LOCAL ADDRESS DETAILS (Please see instuction E at the end)

Same as Current / Permanent / Overseas Address details
Address
Line 1*
Line 2*
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
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.
[Signature / Thumb Impression]
Date: Place : Signature / Thumb Impression of Applicant
Annexure B1
CENTRAL KYC REGISTRY | Know Your Customer (KYC) Application Form | Individual | Related Person
at the end.

1. DETAILS OF RELATED PERSON (Please refer instuction 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

Name*
(If KYC number and name are provided, below details of section 1 are optional)
PROOF OF IDENTITY [PoI] OF RELATED PERSON* (Please see instruction (H) at the end)
B- Voter ID Card
C- PAN Card
E- UID (Aadhaar)
F- NREGA Job Card
Document Type code
• 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.
[Signature / Thumb Impression]
Date: Place : Signature / Thumb Impression of Applicant
3. ATTESTATION / FOR OFFICE USE ONLY

Documents Received Certified Copies
KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS

Date : Name
Emp. Name Code
Emp. Code
Emp. Designation
Emp. Branch

HDFC ERGO General Insurance Company Limited: Know Your Customer (Kyc) Application Form

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HDFC ERGO General Insurance Company Limited

KNOW YOUR CUSTOMER (KYC) APPLICATION FORM

For office use only Application Type* New Update

1. PERSONAL DETAILS (Please refer instuction A at the end)

Date of Birth* 19 -- 03 -- 1994 PHOTO

ADDITIONAL DETAILS REQUIRED* (Mandatry only if section 2 is ticked)

3. PROOF OF IDENTITY(Pol)* (Please refer instuction C at the end)

E- UID (Aadhaar) 461519634068

4. PROOF OF ADDRESS (PoA)*

4.2 CORRESPONDENCE / LOCALADDRESS DETAILS* (Please see instuction E at the end)

Prefix First Name Middle Names Last Name

A- Passport Number Passport Expiry Date

7. REMARKS (If any)

9. ATTESTATION / FOR OFFICE USE ONLY

Documents Received Certified Copies

KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS

List of ISO 3166 two- digit Country Code

For office use only Application Type* New Update

1. CORRESPONDENCE / LOCAL ADDRESS DETAILS (Please see instuction E at the end)

Date: Place : Signature / Thumb Impression of Applicant

For office use only Application Type* New Update

1. DETAILS OF RELATED PERSON (Please refer instuction G at the end)

Prefix First Name Middle Names Last Name

A- Passport Number Passport Expiry Date

3. ATTESTATION / FOR OFFICE USE ONLY

KYC VERIFICATION CARRIED OUT BY INSTITUTION DETAILS

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