Client Details Form V2.0 Client Details v2.0 Step 1 of 2 50% Policy Type*Select a Policy TypeGEMERAURAEDMT0TDRAPTARPDSPSTTDGSPolicy No. (If unknown please tick box on the side)*Policy No. (If unknown please tick box on the side)*Policy No. (If unknown please tick box on the side)*Policy No. (If unknown please tick box on the side)*Policy No. (If unknown please tick box on the side)Policy No. (If unknown please tick box on the side)*Golden Sunset SalutationMr.Miss.Mrs.Dr.First Name*Middle NameLast Name*Please update the information belowSalutationMr.Miss.Mrs.Dr.First Name*Middle NameLast Name*Current Home Address*Town/City*Country*CountryTrinidad and TobagoAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweMobile No.*Home No.Work No.Is your Mobile # your Whatsapp #*YesNoI don't have WhatsappMobile No.Enter the number you can be contacted on WhatsappEmail* Are you a resident of Trinidad and Tobago ?*YesNoFATCA INFORMATIONU.S Citizenship of Lawful Permanent Resident : ( Obtain W-9 )YesNoU.S. Birth Place:YesNo(Obtain W-9 or W-8BEN; and Non-U.S. Passport or similar documentation establishing foreign citizenship; and written explanation regarding U.S. citizenship)U.S. Address :YesNo( Residence, correspondence, or P.O. Box): (Obtain W-9 or W-8BEN; and Non-U.S. passport or similar documentation establishing citizenship )Instructions to transfer funds to U.S. account or directions regularly received from a U.S. address :YesNo( Obtain W-9 or W-8BEN; and documentary evidence establishing Non-U.S. status )Only if address on file is "in care of" or "hold mail" or U.S. P.O. Box; Notice 2011-34 excludes foreign P.O. Box as U.S. Indicia:YesNo( Obtain W-9 or W-8BEN; and documentary evidence establishing Non-U.S. status )Power of Attorney or Signatory Authority granted to person with U.S. address:YesNo( Obtain W-9 or W-8BEN; and documentary evidence establishing Non-U.S. status )Additional InformationPep Status:*YesNoPolitically Exposed PersonMethod of Information Collected*In HouseIn PersonIn House - Email / Telephone For your convenience, all statements and communications from our Company, in the future, may be sent to you via email or Whatsapp messages. If you do not wish to receive such forms of communications, please inform us by sending an email to [email protected]General CommentsSignature of PolicyholderType-in SignatureDigital SignatureIn House Signature*Consent* I confirm that all the above statements are true, accurate and complete. I hereby consent to the disclosure of the above information or details of any transaction related thereto, to any third party as may be required by LAW.Signature* Action Required Please re-check that all your information is correct. When you are finished, return the tablet to the representative to complete the form. Branch of Request*Choose the BranchArimaChaguanasPort of SpainSan FernandoTobagoCSR*Abigail ThomaAnyka QuintinBrianna NelsonIsis SeerattanNicolette JosephCSR*Aartee DanielKamani RameshQuerida PaulSharon GeorgeTianna WeekesCSR*Karen RobinsonLee-Anna ThomasLisa ToolsieShamfa Smith-ClarkeThai'la Reid-DaviesCSR*Claudia Benjamin-EdwardsDarius HartIrma De LabastideSursatee SeepersadCSR*Alicia Guy-McNeilDarah Maynard-DanielDenise De GannesConsent* Acknowledgement that the Policyholder/Premium Payor signed the checklist in the presence of an Authorised Company Representative.Company Representative Signature*Document Checklist* Notarised Passport Completed W-9 or W-8BEN Form Proof of Non-U.S. Citizenship (e.g., Foreign Passport) Written Explanation Regarding U.S. Citizenship (if applicable) Proof of Address Please indicate which documents were received.Date* Date Format: DD slash MM slash YYYY
