Suspicious Transaction Report Form for Insurance Companies, Agents and Brokers. The President of the Kuwait Financial Intelligence Unit

Transcription

1 Suspicious Transaction Report Form for Insurance Companies, Agents and Brokers The President of the Kuwait Financial Intelligence Unit ADDRESS PHONE NUMBER PLEASE REFER TO THE KFIU GUIDE TO COMPLETE SUSPICIOUS TRANSACTION REPORTS FORMS WHEN FILLING OUT THIS FORM. FOR KFIU USE ONLY: Date of Receipt of Report: Number: KFIU Reference I. Reporting Firm Name of the Company: Branch: Address: Date of Disclosure: Name of the Compliance Officer: Direct Mobile Number: Compliance Officer Address: Information about the substituting officer when the compliance officer is absent: Name: Direct Position: Mobile Number: Was a suspicious transaction report previously filed? 1

2 Yes: Please provide KFIU reference number: No: II. Suspicious Transaction Information Information about the Main Subject of the Report A. Subject is a natural person: Full Name: Other names: Gender: Male: Marital Status: Married Female: Unmarried: Date of Birth: Place of Birth: Nationality: Occupation: Employer: Politically Exposed Person? Yes No Start date of the business relationship: Business Address: Residential Address: Mobile phone Number: Identification Number: Type of Identification: Identification Card: Passport/Travel Document: Other: 2

3 B. Subject is a legal person: Company Name: Company Form: Type of Business: Country of Incorporation: Date of Incorporation: Commercial Registration Number: Start date of the business relationship: Address: Managing Entity Information: Name: Person's Name (if other names exist): Gender: Male: Marital Status: Married Date of Birth: Place of Birth: Nationality: Occupation: Employer: Politically Exposed Person? Yes No Business Address: Residential Address: Identification Number: Type of Identification: Identification Card: Female: Unmarried: Passport/Travel Document: 3

4 Other: C. Information about subject with signing authority: Name: Person's Name (if other names exist): Gender: Male: Female: Marital Status: Married Date of Birth: Place of Birth: Nationality: Occupation: Employer: Politically Exposed Person? Yes No Business Address: Residential Address: Identification Number: Type of Identification: Identification Card: Unmarried: Passport/Travel Document: Other: D. Beneficial Owner Information: Name: 4

5 Person's Name (if other names exist): Gender: Male: Female: Marital Status: Married Date of Birth: Place of Birth: Nationality: Occupation: Employer: Politically Exposed Person? Yes No Business Address: Residential Address: Identification Number: Type of Identification: Identification Card: Unmarried: Passport/Travel Document: Other: 2- Subject Policy Details Name of the Insured Person: Name of the Policy Owner: Type of Insurance: Policy Number: Name of Beneficiaries: Date Policy was signed: Date Policy was terminated: Insurance Premium: General Description of Purpose of the Policy: III. Suspicious Transaction Details 5

6 Transaction 1: Transaction Type: Transaction Date: Transaction Status: Transaction Purpose: Currency in which transaction was carried out: Amount transacted: Name of Originator: Originator Account Number or Transaction Number: Name of the Beneficial Owner: Beneficial Owner Account Number (if available): Name of Receiver: Receiver s Account Number: Country of the Receiver: Transaction 2: Transaction Type: Transaction Date: Transaction Status: Transaction Purpose: Currency in which transaction was carried out: Amount transacted: Name of Originator: Originator Account Number or Transaction Number: Name of the Beneficial Owner: Beneficial Owner Account Number (if available): Name of Receiver: Receiver s Account Number: Country of the Receiver: Transaction 3: Transaction Type: Transaction Date: Transaction Status: Transaction Purpose: Currency in which transaction was carried out: Amount transacted: 6

7 Name of Originator: Originator Account Number or Transaction Number: Name of the Beneficial Owner: Beneficial Owner Account Number (if available): Name of Receiver: Receiver s Account Number: Country of the Receiver: IV. Detailed Description of Reason for Reporting 7

8 V. Measures taken by the Entity - Circumstances surrounding the detection of the suspicious transaction: - Internal procedures taken before reporting: - Measures taken in relation to the client after reporting: 8

9 VI. Documents Annexed to the Report 9