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[]
[null,"SOLICITUD DE DATOS DE CLIENTE INDIVIDUAL"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[]
[null,"INFORMACIÓN GENERAL"]
[]
[null,"Estimado (a) Asegurado (a):\n\nEs un gusto tener la oportunidad para saludarle e informarle  que debido a los requerimientos de la Ley Contra el Lavado de Dinero u Otros Activos, es necesario realizar la actualización de sus datos personales por lo menos una vez al año.\n\nPor lo anterior, le solicitamos amablemente completar el formato adjunto y enviarlo a la siguiente direccion: Avenida Reforma 6-20 zona 09, Nivel 04, Ciudad Guatemala, o bien llamar al 2415-1515 para coordinar la entrega.\n\nLe confirmamos que estos datos son de carácter confidencial y de uso exclusivo de la Compañía de Seguros. Agradecemos la confianza que ha depositado en nuestra organización, es para nosotros un privilegio servirle.\n\n\n\n"]
[]
[null,"TIPO DE RELACIÓN",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TIPO DE OPERACIÓN"]
[]
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[]
[null,"DATOS GENERALES DEL CONTRATANTE/ ASEGURADO"]
[]
[null,"(1) Nombres y Apellidos Completos:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(2) Estado Civil:"]
[]
[null,"(3) Documento de Identificación:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(4) Extendido en:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(5) Fecha de emisión:"]
[null,"Tipo:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Número:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Día",null,null,null,null,null,null,null,"Mes",null,null,null,null,null,null,null,null,"Año"]
[null,"(6) Fecha de nacimiento:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(7) Profesión u oficio:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(8) Actividad económica:"]
[null,"Día",null,null,null,null,null,null,null,"Mes",null,null,null,null,null,null,null,null,"Año"]
[null,"(9) Dirección particular completa (calle o avenida, casa No., colonia, sector, lote, manzana, zona, municipio, departamento y país):"]
[]
[null,"(10) Teléfono(s) de residencia:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(11) Teléfono celular:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(12) NIT:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(13) Correo Electrónico:"]
[]
[null,"(14) ¿Es Persona Expuesta Politicamente (PEP), Familia o Asociado cercano de PEP?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(15) ¿Actúa en nombre propio?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"* Nota: Si la respuesta es afirmativa debe completar el formulario Autorización para Inicio de Relaciones Persona Expuesta Politicamente -PEP- y para primas mayores a $2,500.00 deberá llenar el formulario correspondiente."]
[]
[null,"FORMA DE PAGO",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[]
[null,"(16) Seleccione su forma de pago:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Pago en Caja Bantrab",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Visita de Cobrador",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Débito en cuenta Bantrab",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Pago con Tarjeta de Crédito",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"(17) Cargos Mensuales:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(18) Número de Pagos (para pagos con visa cuotas coloque 1 pago):"]
[]
[null,"(19) Si selecciona la opción visita de cobrador, indicar dirección de cobro:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(20) Teléfono de Cobro:"]
[]
[null,"(21) Si selecciona la opción Débito en Cuenta Bantrab, indicar tipo de cuenta:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(22) Número de Cuenta a Debitar:"]
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[null,"(23) Si selecciona la opción Pago con Tarjeta de Crédito, indicar:"]
[null,"(23.1) Banco emisor de la tarjeta:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(23.2) Emisor de la tarjeta:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0]
[null,"(23.3) Número de Tarjeta de Crédito:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(23.4) Nombre del Titular de la Tarjeta:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(23.5) Fecha de Vencimiento:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Mes",null,null,null,null,null,null,null,null,"Año"]
[null,"(23.6) Visa Cuotas o Cuotas Credomatic:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(23.7) Número de Cuotas:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(23.8) Fecha a realizar el cobro:"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,null,null,null,null,null,0]
[null,"(23.9) Documento de Identificación:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(23.10) Extendido en (País, Departamento y Municipio): ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(23.11) Fecha de Nacimiento:"]
[null,"Tipo:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Número:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Día",null,null,null,null,null,null,null,"Mes",null,null,null,null,null,null,null,null,"Año"]
[]
[null,"NOTA IMPORTANTE"]
[]
[null,"Autorizo expresamente a Aseguradora de los Trabajadores, S.A. para que verifique cualquier información de mi persona, en cualquier base de datos pública o privada, con motivo de la regulación aplicable, principalmente la contenida en la Ley de Acceso de la Información Pública (Decreto No. 57-2008).\nSi el responsable de pago es diferente al contratante o asegurado, deberá completarse formulario adicional de acuerdo al tipo de persona (individual o jurídica)."]
[]
[null,"AUTORIZACIÓN DE DÉBITO A CUENTA / CARGO TARJETA DE CRÉDITO"]
[]
[null,"Por medio del presente AUTORIZO expresa e irrevocablemente a ASEGURADORA DE LOS TRABAJADORES, S. A., o quien en el futuro sea mi acreedor(es), parte contractual o entidad con la cual se suscriba contrato de cobro por cuenta ajena; para que puedan efectuar débitos a mi cuenta monetaria o de ahorro de Banco de los Trabajadores, o cargar a mi tarjeta de crédito los montos correspondientes por requerimiento de cobro pactado expresamente en el contrato y conforme a la póliza de seguro indicada en este mismo formulario.\nPara efecto de lo indicado anteriormente, el asegurado o responsable de pago, libera y exonera de toda responsabilidad a Aseguradora de los Trabajadores, S.A., o quien en el futuro sea acreedor, parte contractual o entidad con la cual se suscriba contrato de cobro por cuenta ajena; por el manejo de cuenta constituida en Banco de los Trabajadores y/o por los cargos efectuados en la tarjeta de crédito indicada en el presente."]
[null,"Firma del Asegurado / Responsable de Pago",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Firma de(los) Titular(es) de la Cuenta / Tarjeta"]

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