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41 views

change-of-address-contact-form

Uploaded by

Tham Dang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CHANGE OF ADDRESS / CONTACT FORM

KINDLY COMPLETE FULLY IN BLOCK LETTERS. Please tick boxes (✓) as appropriate and delete at (*) accordingly.
For requests on update to U.S address OR U.S contact number, please complete mandatory Section C FATCA declaration.
Name of Policyholder / Assignee / Trustee (please underline Surname) :

NRIC / Passport No. :

A) CHANGE OF ADDRESS
Please attach copy of NRIC. If address differs from NRIC, please attach Documentary Proof (eg, bank statement, utility
bill not more than 6 months old).
If the option below is not selected, the Change of Address will apply for all existing policies.

□ Apply to all my existing policies □ Only apply to Policy No. :


□ Update Residential Address:
Block / House Unit No# Postal Code

Street / Road

Country

□ Update Mailing Address:


(If different from Residential Address)

Block / House Unit No# Postal Code

Street / Road

Country

B) UPDATE CONTACT DETAILS (This will apply for all existing policies)

Home Number:
(Country Code ) (Area Code + Number)

Office Number:
(Country Code ) (Area Code + Number)

Mobile Number:
(Country Code ) (Area Code + Number)

Email Address:

C) U.S TAX DECLARATION UNDER FOREIGN ACCOUNT TAX COMPLIANCE ACT (FATCA) Policyholder
I am not a U.S Person and I am not acting for / on behalf of a U.S Person / U.S Indicia. If my tax status
changes and I become a U.S Person, I shall notify the Company within 30 days from date of change.
Change of address
*%CSR08*

I am a U.S Person and I have submitted the completed Form W-9.


TIN of Proposer TIN of Joint Life Assured
- - - -
*
Please refer to our company website for the definition of U.S Person and U.S Indicia.
*
Form W-9 / Form W-8BEN / Form W-8BENE can be obtained from http://www.irs.gov.
DECLARATION & AUTHORISATION
a) I hereby request that the policy(ies) stated in this form be changed in accordance with the above applications.
b) I understand and agree that my application is subject to the terms and conditions as stated in the Policy Contract and is
effective only when it has been officially accepted and notified in writing to me by the Company.
Common Reporting Standard
In the event of change of information regarding your tax residence or AEOI classification, please advise us of these changes
promptly and provide a duly completed Self Certification form within 90 days. The form is available at www.tokiomarine.com.
Personal Data Notice
I / We agree and consent that Tokio Marine Life Insurance Singapore Ltd. may collect, use, process and disclose the personal
data in accordance with the terms and conditions as stated in the insurance application form and/or the Tokio Marine Insurance
Group’s Data Protection Policy available at www.tokiomarine.com, which I / we have read, understood and agreed to the same.

Signature of Policyholder / Assignee / Trustee Date

Page 1 of 1 (wef 06092017)

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