Policy Alteration Form Form A

Transcription

1 Policy Alteration Form Form A Filling in this form Please fill in this service form and return the original to 40/F., Tower 1, Times Square, 1 Matheson Street, Causeway Bay, Hong Kong. The change request shall be made to the policy as stated below. If you have any enquiries, please contact our Customer Service Department on (852) For investment choice information, please refer to the relevant investment option booklet. Policy Number Name of First Policy Owner Name of First Life Insured Name of Second Policy Owner Name of Second Life Insured (if applicable) (if applicable) 1. Change of Payment Frequency / Autopay Billing Date / Please complete this section if you wish to apply for a new payment frequency/new autopay billing date. New Payment Frequency: Annually Semi-annually Quarterly Monthly * New Autopay Billing Date* * 5 th 12 th 20 th 27 th Please refer to Payment Method for relevant product. For monthly payment, please complete and return the relevant Autopay Authorisation Form. * Please note that 1 modal premium should be prepaid for the autopay set up and/or change of autopay billing date to take effect. Please refer to the Checklist on the last page for the required supporting documents 2. Reinstatement Please complete this section if you wish to apply for reinstatement. Application for reinstatement shall only be made within 12 months of the termination date of your policy. Reinstatement shall not be applicable for LifeCompass LT, LifeCompass DT, Future Compass RI, Reach Retirement Plan, Steps Regular Investment Plan, Spectrum, Spring and MagicFuture. Reinstatement Please submit the following items Any outstanding premium and additional 1 month premium for monthly premium policy. Relevant autopay authorsation form (Please refer to Payment Method for relevant product). Please note Health Statement Declaration Form should be completed by the Life Insured for underwriting assessment (except Harvest 101 Investment Plan). 3. Riders Please complete this section if you wish to apply to add, change or delete rider benefits. Add Rider(s) / Benefit(s) Change Rider(s) / Benefit(s) Delete Rider(s) / Benefit(s) Rider / Benefit 1 Rider / Benefit 2 Rider / Benefit 3 Sum Insured (if applicable) Sum Insured (if applicable) Sum Insured (if applicable) Premium (if applicable) Premium (if applicable) Premium (if applicable) Please note 1. Health Statement Declaration Form should be completed by Life Insured for underwriting assessment when adding or changing a rider / benefit. 2. The change request will be effective on the following due date upon the underwriting approval. Standard Life Page 1 of 6 PAA_A/TA/0412

2 Policy number 4. Increase Contribution Please complete this section if you wish to apply to make additional regular contribution or single contribution. Additional Regular Contribution Single Contribution Contribution Payment Term year (only applicable to Additional Regular Contribution of Harvest 101 Investment Plan/Harvest Supreme Investment Plan 101 /) Initial Charge Amount $ % (for Aspire Investment Plan only ) Into(amount in policy currency ) Reference Code Percentage Total : 100% Please note 1. The percentage for any selected investment option cannot be less than 10% and must be a whole number. 2. For additional regular contribution, if no investment option / reference code is indicated, the existing investment option allocation will be used. Source of Wealth I/We hereby declare that: Purpose of contribution insurance Protection Planning Children s Education Planning Wealth Accumulation Retirement Planning Target Savings Planning Others, please specify Source of Wealth Savings Retirement / Provident Fund Inheritance Sales of previous Investments / Property Others, please specify Salary HK$ *Please specify total income in the past 12 months Please note 1. For policy with joint ownership, please indicate the source of wealth from all policy owners. 2. We may request additional information or documentation. 3. Please refer to the Checklist on the last page for the required supporting documents. 5. Reduce Regular Contribution Please complete this section if you wish to apply for a reduction of the regular contribution. Reduce Regular Contribution Account No. Reduce Regular Contribution Amount to $ (c ontribution currency same as policy currency ) Standard Life Page 2 of 6

3 Policy number 6. Partial Withdrawal Regular Withdrawal Surrender Please complete this section if you wish to apply for partial withdrawal. Partial withdrawal Account Name and Account No. Withdrawal Amount $ (withdrawal currency same as policy currency) Percentage If you want to withdraw from specific asset(s), please indicate the reference code of investment option and percentage/amount in the following: Reference Code Percentage / Amount Regular withdrawal Please complete this section if you choose to make a regular withdrawal from the policy. Please refer to the relevant product brochure for the details of the minimum withdrawal amount. I/We would like to make a regular withdrawal from: Account Name and Account No. Payment frequency Annually Semi-annually Quarterly Monthly Withdrawal Amount Commencing End date (withdrawal currency same as policy currency ) (date on which withdrawal of the amount stated will start ) (date on which withdrawal will be terminated ) Please complete this section if you wish to apply for surrender or policy paid-up. Surrender Paid Up Important Notes: 1) If this instruction is received on a Hong Kong business day before 3:00pm and approved by Standard Life (Asia) Limited on the same day, it will take effect and be processed on the next Hong Kong business day provided that if such day is a Fund Dealing date. If it is processed on a non-fund Dealing date, it will take effect and be processed on the earliest Hong Kong business day thereafter which is also a Fund Dealing date. 2) Any instruction received on a day which is not a Hong Kong business day or received after 3:00p.m. on a Hong Kong business day will be treated as being received on the next Hong Kong business day before 3:00p.m. 33 3) This transaction will not process until the date on which the respective latest valuation of the investment choice(s) is/are confirmed. 4) The withdrawal amount MUST be equal to or less than the actual investment choice value. 5) If you have not specified the assets from which withdrawal shall be made, the withdrawal will be effected by redeeming the investment options that you have invested in proportion according to their respective value. 6) Percentage must be in a whole number. 7) Exit charge may apply on the above withdrawal request. 8) The withdrawal / surrender value is the (bid) value of the units held less exit charge, if applicable. / 9) Please complete Section 8 for Payment for Partial Withdrawal / Regular Withdrawal / Surrender. / / 10) Partial withdrawal shall be subject to a minimum amount and the value of the policy immediately after partial withdrawal must not be less than the required minimum policy value. 11) Please refer to the Checklist on the last page for the required supporting documents 7. Cancellation of Regular Withdrawal I/We hereby request to cancel the Regular Withdrawal with effect from/ Account Name and Account No. Standard Life Page 3 of 6

4 Policy number 8. Payment Method for Partial Withdrawal / Regular Withdrawal / Surrender / / Payment Currency HKD USD GBP EUR JPY AUD If payment currency in HKD and USD, the payment will be made by cheque. If payment will be remitted by Telegraphic Transfer to your bank account, and a bank charge of HK$300 will be deducted from the withdrawal amount. Please note that bank charges may also be applied by the receiving bank and Standard Life (Asia) Limited will not be responsible for the bank charges. Please fill in you bank accounts particulars below. Do inform Standard Life (Asia) Limited in writing at least 5 days prior to payout date in the event of any changes with the details below. Name of Account Holder (must be the policy owner s bank account ) Bank Account Number Bank Name and Branch Bank Address Swift Code / Sort Code (if applicable ) If payment currency differs from the policy currency, the relevant amount will be paid at the exchange rate determined by us. 9. Declaration and Signature I/We fully understand that an exit charge(s) or equivalent may be deducted from the Policy value in the event of early surrender, withdrawal, or suspension of or reduction in premium, etc. I am/we are fully aware that as a result, I/we may suffer a significant loss of principal and/or bonuses awarded and the surrender value and death benefit may be significantly less than the contribution paid under the Policy as more fully described in the relevant Product Brochure and/or Product Key Facts statement. //// / I/We fully understand the nature, structure and risks of the Policy, the insurance and investment elements of the Policy and the fees and charges at both the Policy level and the underlying investment level. / I/We confirm that: (a), if I/we have selected to pay regular contributions under the Policy, I/we have the ability to make such payments throughout the contribution payment terms; and (b) I/we have sufficient net worth to be able to assume the risks and bear the potential losses of investing in the Policy. I/We have made my/our own determination that the investment is consistent with my investment horizon and investment objectives. At my/our own discretion, I/we confirm that I/we wish to proceed with my/our investment in the Policy; /(a)//(b)/ ///// / With respect to the investment options made available by Standard Life (Asia) Limited ( the Company ) for the allocation of my/our premiums under the Policy after deduction of all applicable fees and charges ( Investment Options ), I/we further understand, acknowledge and agree as follows: ( )/ (i) Any instruction for the subscription, switching, conversion or redemption of the Investment Options shall be in such quantity and value as may be acceptable to the Company in its sole discretion. I/We further acknowledge that any Cash Account, if it is a product feature of the Policy, is not considered as an Investment Option under it; /() (ii) As each of the Investment Options is linked to an external underlying fund, any instruction for the subscription, switching, conversion or redemption of an Investment Option will be effected subject to any restrictions, limitations, fees and charges and other requirements relating to the subscription, switching, conversion or redemption of the relevant underlying fund; (iii) Each Investment Option has its own investment objective, fee structure and risk factors and some of them may invest in whole or in part in derivatives or structured products, hence not all the Investment Options are suitable for the allocation of my Investment Contents. Before I/we give any instruction for the subscription, switching, conversion or redemption of any Investment Option, I/we will evaluate my/our own financial situation, risk tolerance level and will seek professional advice where necessary; / /() (iv) Without limiting the generality of the foregoing, the Company reserves the right to reject, suspend or defer any instruction to subscribe for, switch, convert or redeem any Investment Option, in such manner and to the extent necessary, as determined by the Company, to comply with any restrictions, limitations or other requirements relating to the subscription, switching, conversion or redemption (including any restrictions or limitations associated with excessive trading, short term trading or market timing) of the relevant underlying fund; () (v) Without limiting the generality of the foregoing, the Company may deduct from an Investment Option any amounts to cover any fees, charges or expenses (including any fees and charges associated with excessive trading or short term trading) incurred by the Company in connection with the subscription, switching, conversion or redemption of the relevant underlying fund; ( ) Standard Life Page 4 of 6

5 Policy number (vi) (vii) (viii) The restrictions, limitations, fees and charges and other requirements relating to the subscription, switching, conversion or redemption of the underlying funds are set out in the offering documents, prospectuses and constitutive documents of the relevant underlying funds, and I am/we are deemed to have read and understood such offering documents, prospectuses and constitutive documents before giving any instruction to the Company for the subscription, switching, conversion or redemption of Investment Options; / The Company shall not in any event be liable to me/us for any losses, damages or expenses whatsoever arising out of or in connection with any failure or delay in processing any instruction for the subscription, switching, conversion or redemption of Investment Options; and / Whenever there is a switch of investments or funds between two Investment Options or between an Investment Option an a Cash Account, the currency denomination of any funds or proceeds from the switch-out Cash Account or Investment Option which are not HK$ denominated will first be converted to HK$; and if the switch-in Cash Account or Investment Option is not denominated in HK$, the currency denomination of such funds or proceeds will further be converted into that non-hk$ currency of the switch-in Cash Account or for the purchase of the switch-in Investment Option. This is the case notwithstanding that the switch-out Cash Account or Investment Option is in the same currency as the switch-in Cash Account or Investment Option. I/We further acknowledge and agree that I/we shall bear all the currency exchange spread and risks associated with such currency conversions. // In submitting this service form, I/we agree that my/our personal information may be transferred to (i) any related companies or any service providers for providing services to me/us; (ii) any regulatory or governmental bodies to enable them to carry out their regulatory functions; (iii) any association, federation or similar organisation of insurance companies ("Federation") that exists or is formed from time to time for any related purposes or to enable the Federation to carry out its regulatory functions or such other functions that may be assigned to the Federation from time to time and are reasonably required in the interest of the insurance industry or any member(s) of the Federation; and (iv) any members of the Federation for any of the above purposes. I/We understand that failure to supply the data requested in this application form may result in the Company being unable to process this application or provision of insurance and other financial services. //(i)(ii) (iii) (iv)/ I/We understand that I/we have the right under the Personal Data (Privacy) Ordinance ( PDPO ) to request access to and correction of all of my/our personal information unless there is an applicable exemption under the PDPO under which the Company may refuse to do so. I/We may also request you to inform me/us of the type of personal information held by you about me/us. In accordance with the provision of the PDPO, the Company has the right to charge reasonable fee for processing such data access and correction request. If I/we want to access or correct my/our personal information held by the Company, I/we may make requests to your Customer Service Manager at 40th Floor, Tower 1, Times Square, 1 Matheson Street, Causeway Bay, Hong Kong. I/We can at any time request the Company to cease using my/our personal information for direct marketing purposes. /()/// /// //() // I/We further acknowledge that I/we have been given sufficient time to seek independent advice (legal, financial or otherwise) in relation to this Application and the declarations made in the above, the Chinese version of the declarations is translated for my/our reference only. //()/ Signature of First Policy Owner Signature of Second Policy Owner (if applicable) Signature of First Life Insured Signature of Second Life Insured (if applicable) Signature of Policy Assignee (for collateral assignment only) (if applicable) Standard Life Page 5 of 6

6 Policy number Checklist In order to process effectively, please provide the following document and information with the Policy Alteration Form Form A and tick alongside all the following boxes when completed. Change of Payment Frequency / Autopay Billng Date 1) Provide information about the policy: (i) Policy number; (ii) Name of Policy Owner(s); and (iii) Name of Life Insured(s) 2) Complete Section 1 3) For monthly payment, please complete and return the relevant Autopay Authorisation Form. 4) The name of the payer must be the same as the policy owner. 5) Read the declarations in Section 9. Please sign and date Section 9 by all relevant parties. Increase Contribution 1) Provide information about the policy: (i) Policy number; (ii) Name of Policy Owner(s); and (iii) Name of Life Insured(s) 2) Complete Section 4 3) Submit HKID / valid passport copy 4) We reserve the right to request additional information or documentation on source of wealth where we deem necessary. 5) Read the declarations in Section 9. Please sign and date Section 9 by all relevant parties. Partial Withdrawal / Regular Withdrawal / Surrender 1) Provide information about the policy: (i) Policy number; (ii) Name of Policy Owner(s); and (iii) Name of Life Insured(s) 2) Complete Section 6 3) Submit HKID / valid passport copy 4) Read the declarations in Section 9. Please sign and date Section 9 by all relevant parties. Copy of original supporting documents submitted (including identification document and proof of residential address (and permanent address if different)) must be properly certified by suitable certifiers as set out in the Anti-Money Laundering and Counter-Terrorist Financing (Financial Institutions) Ordinance. The certifier must (i) state that the copy document is a true copy of the original; (ii) sign and date the copy document (printing his/ her name clearly in capitals underneath); and (iii) clearly indicate his/ her position or capacity on it. Standard Life (Asia) Limited is a subsidiary of Standard Life plc. 40/F, Tower 1, Times Square, 1 Matheson Street, Causeway Bay, Hong Kong Tel Fax Standard Life Page 6 of 6