Life Annuity Application The Application Form Process Personal Information Plan Information Underwriting Declarations Details about the Proposer (policyholder) and the Insured (the person being covered). Details about the selected policy and its riders. Other cri cal informa on needed to process your applica on. Everything to take note of before you sign. Submission Checklist Please check that you have included all the necessary documents. Any omissions may result in a delay of the processing of your applica on. Photocopy of NRIC or FIN or other relevant iden ty documents, if applicable Proof of address documenta on, if applicable Tax residency cer fica on for FATCA and/or CRS, if applicable All relevant underwri ng forms Copy of medical reports or test results, if applicable For Official Use Only For Adviser Use Only Receipt number Adviser code Payment received date (dd/mm/yyyy) Adviser name / / Source code Policy delivery method By mail By hand If no op on is indicated, the policy will be sent by mail. NTUC Income Insurance Co-operative Limited Income Centre 75 Bras Basah Road Singapore 189557 Tel: 6788 1777 Fax: 6338 1500 Email: csquery@income.com.sg Website: www.income.com.sg Income/LHO/Life(Annuity)/10/2017 1 of 11
PLEASE USE BLOCK LETTERS TO COMPLETE THIS FORM. If you require addi onal space for your answer, please state the ques on number and answer clearly on page 8.! WARNING: STATEMENT UNDER SECTION 25 5 OF THE INSURANCE ACT, CAP. 142 OR ANY FUTURE AMENDMENTS TO IT YOU MUST REVEAL ALL FACTS YOU KNOW, OR OUGHT TO KNOW, WHICH MAY AFFECT THE INSURANCE COVER YOU ARE APPLYING FOR. OTHERWISE, THE INSURANCE POLICY MAY NOT BE VALID. 1 Proposer Details (Policyholder) 1.1 Personal Particulars Full name (as in NRIC or FIN) NRIC/Passport number/fin Date of birth (dd/mm/yyyy) Gender Male / / Female Na onality Country of birth Marital status Singaporean Others Single Singapore PR (Na onality) Married Widowed Divorced 1.2 Work Details Occupa on Name of organisa on Nature of work Annual income (S$) 1.3 Contact Information Contact number Please provide at least one number Mobile Home Work Email address Residen al address Postal code Country Mailing address If different from residen al address Postal code Country Important Notes: For exis ng Income policyholders, if your contact informa on on this form is different from those in our records, we will automa cally update all your exis ng policies with the new informa on. If you DO NOT want us to update the contact informa on for specific policies, please state the policy number(s) here: 1. 2. 3. Residen al address verifica on For Singapore Ci zen/permanent Resident If the residen al address stated in the applica on form is different from the address in your iden ty document, please provide billing proof. 2 of 11 Income/LHO/Life(Annuity)/10/2017
For non-singapore Ci zen Please provide a valid iden ty document or passport with your residen al address indicated, or billing proof. Examples of billing proof u lity bills, bank statements and le ers issued by statutory or government bodies (dated within past 6 months) with le erhead, name, address and date clearly shown. 1.4 Details Of Next-Of-Kin Full name (as in NRIC or FIN) NRIC/Passport number/fin Contact number Please provide at least one number Rela onship to Proposer Mobile Home Work 2 Tax Residency Declaration Important Notes: If you are required to self-cer fy on behalf of any En ty Account Holder, please complete and submit a FATCA and CRS self-cer fica on form for En ty Account Holder. You do not need to complete this sec on. If you are a Controlling Person of any En ty, please complete and submit a FATCA and CRS self-cer fica on form for Controlling Person. You do not need to complete this sec on. If there are mul ple Account Holders, please submit a separate form for each Account Holder. If you require further details, please consult your tax/legal adviser or local tax authority. It is important for you to provide us with complete and accurate informa on in this form, as these are pursuant to requirements under Singapore Income Tax Act (Chapter 134) and its subsidiary legisla on. If any informa on should change in the future, please no fy us promptly. 1. Are you a tax resident of Singapore? Yes, I am solely a tax resident of Singapore and do not have a foreign tax residency. My Singapore TIN is my NRIC or FIN. If your TIN is not your NRIC or FIN, please state it here: No, I am currently a tax resident in the following list of countries/jurisdic ons (include Singapore, if applicable and provide details below): No. Country(ies) or jurisdic on(s) of tax residence^ Tax Iden fica on Number (TIN) If TIN is not available, please ck ( ) the reason code (refer to Table 1 below) If reason B is selected, please indicate why TIN is not available 1 A B C 2 3 A B C A B C ^If you are a United States (U.S.) ci zen or U.S. resident for tax purposes, you are required to submit Form W-9. Table 1 Reason code Descrip on A The country/jurisdic on where the account holder is resident does not issue TINs to its residents. B The account holder is otherwise unable to obtain a TIN or equivalent number. (Please explain why you are unable to obtain a TIN if you have selected this reason). C No TIN is required. (Note: Only select this reason if the domes c law of the relevant jurisdic on does not require the collec on of the TIN issued by such jurisdic on). Please refer to the OECD website for more informa on on tax residency: h p://www.oecd.org/tax/automa c-exchange/crs-implementa on-and-assistance/tax-residency/ Income/LHO/Life(Annuity)/10/2017 3 of 11
2. If your residen al address (or contact number) is different from your country(ies) of tax residence, please select a reason that applies: Tick ( ) ONE only and submit relevant supporting documents: Student at an educa on ins tu on in the country of residence. Working in the country of residence for less than 6 months. On an educa onal or cultural exchange visitor program in the country of residence for less than 6 months. Regular travel between jurisdic ons for work and home. Others (Please specify) 3 Beneficial Ownership Declaration This is NOT a nomina on of beneficiaries for this policy A Beneficial Owner is defined in the MAS No ce on Preven on of Money Laundering and Countering the Financing of Terrorism as an individual who ul mately owns or controls the customer or the individual on whose behalf business rela ons are established. If there is a Beneficial Ownership arrangement, please 1. Submit a copy of their NRIC or passport and a completed copy of the FATCA and CRS self-cer fica on form for Individual Account Holder, En ty Account Holder or Controlling Person available here: www.income.com.sg/policy-downloads-and-forms; and 2. Provide details below: Name of Beneficial Owner NRIC/Passport number/fin Date of birth (dd/mm/yyyy) Na onality Singaporean Singapore PR (Na onality) Others Gender Male Female Rela onship to Proposer 4 Politically Exposed Person (PEP) Declaration A Poli cally Exposed Person (PEP) is an individual who is, or has been entrusted with prominent public func ons whether in Singapore, a foreign country or an interna onal organisa on. Prominent public func on includes the roles held by head of state, a head of government, government ministers, senior civil or public servants, senior judicial or military officials, senior execu ves of state owned corpora ons, senior poli cal party officials, members of the legislature, and senior management of interna onal organisa ons. If you, or the Beneficial Owner, are a PEP or related^ to a PEP, you must disclose this informa on. ^An individual closely connected to a PEP either socially or professionally, such as a parent, stepparent, child, stepchild, adopted child, spouse, sibling, step-sibling, or adopted sibling. Name of PEP Title of PEP Name of person related to PEP Rela onship to PEP 5 Policy Information 5.1 Plan Details Please state the name of the plan for this applica on. Name of plan Total premium due 4 of 11 Income/LHO/Life(Annuity)/10/2017
5.2 Annuity Payout Arrangement Frequency Annuity instalment payment Monthly Quarterly Half-yearly Yearly For cash applica on, the annuity instalment payment will be credited to your bank account. Please provide the account details below: Name of account holder NRIC number Name of bank and branch Bank account number If the above informa on provided is incorrect or incomplete, the annuity instalment payment will be via cheque For SRS applica on, the annuity instalment payment will be credited to your SRS account. 6 Premium Payment Information 6.1 Payment Method Cashier order 1 / Cash / Money order Supplementary Re rement Scheme Account Cheque (Cheque number) payable to "NTUC Income" Important Notes: 1 For payment by cashier s order, please submit a copy of the cashier s order applica on form or debit advice with Payor s details. 6.2 Payor Details The Payor refers to the person making the premium by cheque, cashier's order, credit card or GIRO applica on. Is the Proposer the Payor? Yes. No. Please disclose Payor details. Payor name (as in NRIC or FIN) NRIC/Passport number/fin Occupa on Rela onship to Proposer Parent Spouse Child Others Please state reason for paying the premiums on behalf of Proposer 6.3 Source Of Funds And Wealth 1. Source of Funds a. Who is funding the insurance premium for this applica on? Proposer/Payor Others. Please provide details below: Name of person funding the policy NRIC/Passport number/fin Rela onship to Proposer Occupa on and organisa on Income/LHO/Life(Annuity)/10/2017 5 of 11
b. What is the source of funds used to pay the premiums? Salary or commission Inheritance Personal savings If currently not employed, please provide details below (for example: previous employment, allowance from family members) Proceeds from a policy Sale of assets Others Please provide details below Details for Personal savings/others 2. How did you accumulate your wealth (i.e. your total assets)? You may choose more than one op on. Salary or commission from current and/or past employment Inheritance and gi s Sale of property, company, or other assets Business or trade income Investments (shares, bonds, unit trusts, etc.) Others 6.4 Payment Authorisation Please complete all the relevant sec ons 6.4.1 Supplementary Retirement Scheme (SRS) Account I authorise NTUC Income Insurance Co-opera ve Limited ( Income ) to deduct the premium from my SRS account once the policy is accepted. SRS operator SRS account number 7 Retirement Sum Scheme (RSS) Exemption For cash applica on only Please ck for RSS Exemp on Yes No Important Notes: A CPF member below age 55 may seek exemp on from se ng aside a Re rement Sum if the annuity policies provide a monthly income for re rement. A CPF member age 55 and above may seek exemp on from se ng aside a Re rement Sum if the annuity policies sa sfy the following condi ons: 1. The monthly annuity payment to the CPF member must be for life and will only cease upon the death of the CPF member. 2. The monthly annuity payment must commence at age no later than the draw down age (i.e. 62, 63, 64 and 65). 3. The insurer is agreeable to add the following terms to the policy: i. Where the annuitant cancels the annuity policy for its cash surrender value the insurer shall transfer all the money represen ng the surrender value of the annuity or an amount equal to the value of the Re rement Sum plus accrued interest as determined by the CPF Board (CPFB), to the annuitant s Re rement Account CPFB. ii. Where a loan of the cash surrender value of the policy is granted to the annuitant, CPFB shall have a first charge on the policy to secure the refund of an amount equal to the Re rement Sum plus accrued interests as determined by the CPFB to the annuitant s Re rement Account. The insurer shall not be en tled to use part or all of any annuity payment falling due to repay the outstanding loan. 4. If the monthly annuity payment is equal to or more than the CPF member s cohort Re rement Sum monthly payment, full exemp on can be granted. If not, the CPF member will have to set aside a reduced Re rement Sum, in the form of cash or property pledge or both or as determined by CPFB. CPF members who wish to seek exemp on for RSS are required to bring their policy document to CPFB for approval. If the request is approved, CPFB will write to the insurer to pass endorsement on the annuity policy. 6 of 11 Income/LHO/Life(Annuity)/10/2017
8 Concurrent Insurance Applications & Policies 1. Do you have any exis ng policies or proposal pending approval? If yes, please provide details: Yes No Insurance company Year of issue or applica on Death coverage amount (S$) Total and permanent disability coverage amount (S$) Cri cal illness coverage amount (S$) Personal accident coverage amount (S$) Disability income coverage amount (S$) Others Please specify type and coverage Policy/Proposal Policy/Proposal Policy/Proposal! WARNING: We would not advise you to replace an exis ng policy with a new one. Some of the disadvantages are: a. the insurance may not be granted on standard terms; b. you may have to pay a higher premium as you are now older; and c. you will lose financial benefits built up over the years. Please consult your present insurer before making a final decision. Make a careful comparison so that you can be sure that you are making a decision that is in your best interest. 2. Is the insurance you are applying for to replace or intended to replace in full or in part, any policy with Income or other insurers? If yes, what is it replacing? Please provide details below: Yes No Insurance company Policy details Please provide policy number and policy type Reason(s) for replacing policy Policy Policy Policy Income/LHO/Life(Annuity)/10/2017 7 of 11
9 Additional Details If you require addi onal space for your answer to any of the ques ons, please write the ques on number and answer below: 10 Personal Data Consent 10.1 Personal Data The informa on I have provided is my personal data and, where it is not, I have the consent of the owner of the personal data to provide such informa on. The personal data includes personal data provided in this applica on or any document to Income, whether by me or any other party or source for this applica on. By providing this informa on, I or we understand, and give my or our consent for Income as well as Income s respec ve representa ves and agents to collect, use, store, transfer and disclose the informa on, to or with all such persons (including Income s third party service providers, whether located within or outside of Singapore) for the purpose of enabling Income to provide me with the services required of by an insurer, including the evalua on, processing, administering and/or managing of my rela onship and policies with Income and for the purposes set out in Income s Privacy Policy which can be found at h p://www.income.com.sg/privacy-policy ( How we use your personal data (Purpose & No fica on Obliga on) ). You may withdraw your consent, access or correct your personal data by wri ng to DPO@income.com.sg or to The Data Protec on Officer, Income Centre, 75 Bras Basah Road, Singapore 189557. 10.2 Income Rewards Programme Do you want to join the rewards programme? Yes 10.3 Marketing Material Do you want to receive marke ng and promo onal materials about Income s financial products, related services, programmes, and events via telephone calls, text messages, faxes, mails, or emails? Yes No No If you do not make a selec on, Income will follow any exis ng op ons you may have previously indicated. Income will use the contact details you have provided in this form to contact you. 8 of 11 Income/LHO/Life(Annuity)/10/2017
11 Declarations 1. I declare that the informa on provided in this applica on, and in all documents to Income or its Medical Examiner are true, correct, and complete, and no material facts likely to influence the assessment and acceptance of this applica on have been withheld to the best of my knowledge. I accept full responsibility for them, whether wri en by me or by anyone else on my behalf. I agree that this applica on and other wri en answers, statements, informa on, or declara ons made by me or on my behalf will form the basis of the contract of insurance between me and you. If anything is untrue, incorrect, or incomplete, the insurance policy will not be valid. 2. I will no fy Income immediately if there is any change in the state of my health, or if I plan to seek medical consulta on, inves ga on, or treatment between the date of this applica on and the date this policy is in force. You may add special terms to the policy according to the informa on provided. This applies if I am applying for a non-guaranteed issue basic plan or for any non-guaranteed issue riders. 3. I authorise, consent to, and agree to any medical source, insurance office, reinsurer, or organisa on to release to you and you to release to any medical source, insurance office, reinsurer or organisa on any relevant informa on to do with me or the Insured whether you accept my applica on or not. A photocopy of this authorisa on is valid as an original copy. 4. I agree that Income s legal responsibility will only begin when we accept this applica on and I have paid the first premium. 5. I have confirmed that I am not an undischarged bankrupt and no bankruptcy applica on (including any statutory order) or order has been made against me. 6. I confirm that the en re marke ng and selling process for my proposed insurance applica on has been carried out in Singapore. 7. I agree that the policy is issued as a Singapore Policy and agree that the policy will be entered in the Register of the Singapore policies. 8. I confirm that I understand and agree to the Personal Data Use Statement on: www.income.com.sg. 9. I agree and expressly consent that Income shall have the right to provide my personal data and informa on to any governmental authori es, regulatory bodies and/or any other person(s) to fulfil its obliga ons under applicable tax regula ons, including Singapore Income Tax Act (Chapter 134), the Foreign Account Tax Compliance Act ( FATCA ) and the OECD Common Repor ng Standard for Common Exchange of Financial Account Informa on ( CRS ). I understand that such disclosures may: a. Involve cross border transfer of personal data and informa on outside the jurisdic on; b. Be in respect to personal data and informa on provided in this form, or in any document provided, or to be provided to Income by me or from other sources; and c. Relate to personal data of the Account Holder and any informa on about relevant policy or policies. 10. I understand that Income will not be able to sell or administer any insurance product or provide any services to me if I refuse to give this expressed consent. 11. I cer fy that I am the Account Holder (or am authorised to sign for the Account Holder) of all accounts to which this form relates. 12. I declare that all statements made in this form are correct and complete. I undertake to inform Income within 30 days if there is a change in circumstances that affects the tax residency status of the Account Holder or causes the informa on in this form to be incorrect or incomplete. I shall provide Income with an updated FATCA and CRS self-cer fica on form within 90 days of such change in circumstances. I understand any false, misleading, or fraudulent informa on regarding my resident status for tax purposes may result in certain penal es. 13. I understand that it is usually not a good idea for me to replace an exis ng investment product (for example: life policy / investment-linked policy / unit trust) with a new investment product, whether from the same or a different financial ins tu on. I further understand that some of the disadvantages of replacement are: a. the insurance may not be granted on standard terms; b. I may have to pay a higher premium as the Insured or I am now older; and c. I will lose financial benefits built up over the years. 14. I agree that the product summary and the benefit illustra on, if applicable, have been explained to me to my sa sfac on by my adviser. 15. I am aware that I can ask for a copy of Your Guide to Life Insurance and/or Your Guide to Health Insurance from my adviser. Or I can download them from: www.income.com.sg. 16. If I have applied to become a member of Income Rewards, I agree to keep to your by-laws. 17. I acknowledge that I am responsible for making sure that I am allowed to buy this plan under the laws and regula ons that apply to my na onality and the country that I reside in. I understand that Income cannot accept liability for any legal consequences under the laws of any other country or any tax effects that may arise in connec on with the purchase of this plan. I declare that any funds and assets I place with Income, and any profits generated from them, comply with the tax laws of the countries where I am a resident of, and a ci zen of. 18. If a Cancer Premium Waiver (GIO) rider is added, I am aware that the rider covers diagnosis of major cancer as defined in its contract. I understand and agree that if the Insured had consulted a doctor for, suffered symptoms of, was inves gated for, was diagnosed with, or received medical treatment for any cancer, including carcinoma-in-situ, before the cover start date, no benefit will be paid under the rider, and the rider will be terminated. Cover start date means the date Income issues the rider, issues an endorsement to include or increase a benefit, or reinstates the rider, whichever is latest. 19. If Annex I is applicable, I confirm and understand that all other sec ons of this applica on, including all Declara ons will also apply to Annex I. Income/LHO/Life(Annuity)/10/2017 9 of 11
I agree that if I do not reveal any significant facts in this applica on (which would have affected Income s decision to accept my applica on on standard terms), any policy issued may be invalid. This includes any facts I may not be sure is significant, and any informa on I have given to my adviser but was not included in the applica on. Signature of Proposer Signed in Singapore on (dd/mm/yyyy) Signature of Witness Age 21 and above Signed in Singapore on (dd/mm/yyyy) Full name of Witness NRIC/Passport number/fin 12 Adviser Declaration All answers given to me by the Proposer and/or Insured are in the applica on. I have not withheld any informa on which may influence Income s decision to accept this applica on. I have personally seen the Proposer and/or Insured, and have explained the terms of the plan to the Proposer. I have seen all the original iden fica on documents, and have submi ed photocopies of them with this applica on. I confirm that all submi ed documents are copies of their originals. Name of Adviser (as in NRIC) Signature of Adviser Signed in Singapore on (dd/mm/yyyy) 10 of 11 Income/LHO/Life(Annuity)/10/2017
Appendix Defined Terms Note: These are selected summaries of defined terms provided to assist you with the comple on of a FATCA and CRS self-cer fica on form. Further details can be found within the OECD Common Repor ng Standard for Automa c Exchange of Financial Account Informa on (the CRS ), the associated Commentary to the CRS, and domes c guidance. This can be found at the OECD automa c exchange of informa on portal. Term Account Holder FATCA Financial Account Par cipa ng Jurisdic on En ty Control Controlling Person(s) Reportable Account Reportable Jurisdic on Reportable Person TIN (including func onal equivalent ) Descrip on The term Account Holder means the person listed or iden fied as the holder of a Financial Account. A person, other than a financial ins tu on, holding a Financial Account for the benefit of another person as an agent, a custodian, a nominee, a signatory, an investment advisor, an intermediary, or as a legal guardian, is not treated as the Account Holder. In these circumstances, that other person is the Account Holder. For example, in the case of a parent/child rela onship where the parent is ac ng as a legal guardian, the child is regarded as the Account Holder. With respect to a jointly held account, each joint holder is treated as an Account Holder. An Account Holder for purposes of this self cer fica on may refer to a Proposer (eventually the Policyowner), Controlling Person, Beneficial Owner, Assignee, Trustee, Beneficiary under a Trust or a Trust Nominee named under sec on 49L of the Singapore Insurance Act (Chapter 142). FATCA stands for the U.S. provisions commonly known as the Foreign Account Tax Compliance Act, which were enacted into U.S. law as part of the Hiring Incen ves to Restore Employment (HIRE) Act on March 18, 2010. FATCA creates a new informa on repor ng and withholding regime for payments made to certain non-u.s. financial ins tu ons and other non-u.s. en es. A Financial Account is an account maintained by a Financial Ins tu on and includes: Depository Accounts; Custodial Accounts; Equity and debt interest in certain Investment En es; Cash Value Insurance Contracts; and Annuity Contracts. A Par cipa ng Jurisdic on means a jurisdic on with which an agreement is in place pursuant to which it will provide the informa on required on the automa c exchange of financial account informa on set out in the Common Repor ng Standard and that is iden fied in a published list. The term En ty means a legal person or a legal arrangement, such as a corpora on, organisa on, partnership, trust or founda on. Control over an En ty is generally exercised by the natural person(s) who ul mately has a controlling ownership interest (typically on the basis of a certain percentage (e.g. 25%)) in the En ty. Where no natural person(s) exercises control through ownership interests, the Controlling Person(s) of the En ty will be the natural person(s) who exercises control of the En ty through other means. Where no natural person or persons are iden fied as exercising control of the En ty through ownership interests, the Controlling Person of the En ty is deemed to be the natural person who holds the posi on of senior managing official. Controlling Persons are the natural person(s) who exercise control over an en ty. Where that en ty is treated as a Passive Non-Financial En ty ( Passive NFE ) then a Financial Ins tu on is required to determine whether or not these Controlling Persons are Reportable Persons. This defini on corresponds to the term beneficial owner described in Recommenda on 10 and the Interpreta ve Note on Recommenda on 10 of the Financial Ac on Task Force Recommenda ons (as adopted in February 2012). In the case of a trust, the Controlling Person(s) are the se lor(s), the trustee(s), the protector(s) (if any), the beneficiary(ies) or class(es) of beneficiaries, or any other natural person(s) exercising ul mate effec ve control over the trust (including through a chain of control or ownership). Under the CRS the se lor(s), the trustee(s), the protector(s) (if any), and the beneficiary(ies) or class(es) of beneficiaries, are always treated as Controlling Persons of a trust, regardless of whether or not any of them exercises control over the ac vi es of the trust. Where the se lor(s) of a trust is an En ty then the CRS requires Financial Ins tu ons to also iden fy the Controlling Persons of the se lor(s) and when required report them as Controlling Persons of the trust. In the case of a legal arrangement other than a trust, Controlling Person(s) means persons in equivalent or similar posi ons. The term Reportable Account means an account held by one or more Reportable Persons or by a Passive NFE with one or more Controlling Persons that is a Reportable Person. A Reportable Jurisdic on is a jurisdic on with which an obliga on to provide financial account informa on is in place and that is iden fied in a published list. A Reportable Person is an individual (or en ty) that is tax resident in a Reportable Jurisdic on under the laws of that jurisdic on. The Account Holder will normally be the Reportable Person ; however, in the case of an Account Holder that is a Passive NFE, a Reportable Person also includes any Controlling Persons who are tax resident in a Reportable Jurisdic on. Dual resident individuals may rely on the ebreaker rules contained in tax conven ons (if applicable) to solve cases of double residence for purposes of determining their residence for tax purposes. The term TIN means Taxpayer Iden fica on Number or a func onal equivalent in the absence of a TIN. A TIN is a unique combina on of le ers or numbers assigned by a jurisdic on to an individual or an En ty and used to iden fy the individual or En ty for the purposes of administering the tax laws of such jurisdic on. Further details of acceptable TINs can be found at the OECD automa c exchange of informa on portal. Some jurisdic ons do not issue a TIN. However, these jurisdic ons o en u lize some other high integrity number with an equivalent level of iden fica on (a func onal equivalent ). Examples of that type of number include, for individuals, a social security/insurance number, ci zen/ personal iden fica on/service code/number, and resident registra on number. PO#17005455/08/17 Income/LHO/Life(Annuity)/10/2017 11 of 11
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