Self certification form – individual policyholder

SELF CERTIFICATION FORM – INDIVIDUAL POLICYHOLDER
One form should be completed by each policyholder.
Where the settlor or beneficial owner of the contract differs from the contract owner(s) a separate self-certification form
should be completed for each party.
Prior to completing this form please read the Important Notes for guidance.
Policyholder
Policy numbers
Permanent residential address including country and postcode (see Important Note 4)
Tax residency countries (see Important Note 5)
Tax Identification Numbers
(for a UK Tax Resident Individual this is
your National Insurance Number)
Tax details 1
Tax details 2
Tax details 3
I am a tax resident in the jurisdictions stated above and no other Yes
No
Are you a US Citizen or resident alien with an obligation to file any tax returns
(income, estate, gift or the like) to the US Internal Revenue Service (“IRS”)? Yes
No
Email address (see Important Note 6)
Telephone numbers
Country
code
Area code
Phone number
Home
Mobile/Cell
Important Notes
1. Please note that if you have access to an OnLine Account, any change of email address will be updated on this system
and your logon will use the new email address.
2. If your signature does not match our records we will be unable to carry out your instructions. You will be asked to supply
suitably certified identification and/or a specimen signature form, together with a new instruction.
3. We will act upon faxed or electronic instructions, it is not necessary to send the original form.
4. The country stated in your residential address will be used as your country of residence. It is important that this information
is recorded correctly as it may affect your tax position.
5. Different Countries have their own tax rules and laws. It is possible to be resident in more than one country at the same time.
If you are tax resident in more than one country (this includes a US Citizen even if resident in another jurisdiction), please
disclose all residencies. If you are unsure of your obligations for tax residency you should seek independent advice from an
Independent Tax Advisor.
6. If you request the Company to communicate with you by email, you agree that this is entirely at your own risk and this
will be taken as confirmation that you understand that email communication is not secure and may be intercepted by
unauthorised third parties. In such circumstances, you will be taken as agreeing that the Company shall not be held
responsible in any way should emails be intercepted by unauthorised third parties who gain access to your personal data.
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7. A growing group of countries have entered into an Intergovernmental Agreement (IGA) with the US following the
implementation of the Foreign Account Tax Compliance Act (FATCA). Additionally, the Organisation for Economic
Cooperation and Development (OECD) has developed a Standard for Automatic Exchange of Financial Information in
tax matters “Common Reporting Standard” (CRS) which is a new single global standard for the automatic exchange of
information between key authorities worldwide. In light of regulatory changes which have extra territorial impact, you will be
required in the future to supply additional data, including tax information.
I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct and complete.
Policyholder
Signature
Date
D D M M Y
Y
Y
Y
Hansard Europe Limited
Carysfort House, Carysfort Avenue, Blackrock, Co. Dublin, Republic of Ireland
Telephone: +353 1 211 2800 Fax: +353 1 211 2850/2860 Website: hansard.com
Registered Number 219727. Registered Office: IFSC, 25/28 North Wall Quay, Dublin 1, Republic of Ireland
Hansard Europe Limited is regulated by the Central Bank of Ireland (www.centralbank.ie)
EO0476O 27/04/15
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