契約內容變更申請書(OIU)

契約內容變更申請書(OIU)


保 單

號 碼

要 保 人

被 保 險 人

本申請書經 貴公司同意簽章後構成原契約之一部分，其契約內容如下：

1. 地址、電話變更

□ 住所地址 □ 要保人所有保單一併變更

居留(住)國     地址                        

□ 要保人永久住所地址 □ 同聯絡地址

居留(住)國     地址                        

□ 電話變更

住所電話            工作電話             行動電話         

2. 要保人/繼任持有人變更

□ 新要保人姓名 □ 繼任持有人姓名(英文)-須與護照相同              

□ 要保人資料

□ 繼任持有人資料

□ 新要保人姓名 □ 繼任持有人姓名(中文)          


與被保險人關係 商業登記證/護照號碼          


出生日期 性別               


出生地   國籍               


居留(住)國 住所電話號碼            


工作電話號碼 行動電話號碼            


電子郵件地址                       與被保險人關係            


僱主(公司)名稱                           


行業或公司業務性質                         


職業                               


工作內容                             


□ 新要保人 □ 繼任持有人 住所地址                   


□ 新要保人 □ 繼任持有人 永久住所地址                  


1. 變更後本人(即新要保人)願負本保單所有權利與義務，若有爭議，本人願負一切法律責任，與貴公司無涉。

2. 本保單續期保費繳費為信用卡付費或金融機構轉帳件者，變更要保人請一併重新填寫『保險費繳費授權書』。

3. 請檢附 1.遵循美國外國帳戶稅收遵從法(FATCA)聲明書 2.新要保人身分證明文件。

4. 請檢附作為驗證使用之居住地址證明，包括此要保書簽署日期前三個月內發出的公用事業帳單，例如，電


費單、電話費單等

3. 身故受益人變更

※勿指定法定繼承人

※百分比總和必須等於

100%。

□ 順位 □ 比例   %

姓名(英文)-須與護照相同 商業登記證/護照號碼                   與被保險人關係         

□ 順位 □ 比例   %

姓名(英文)-須與護照相同 商業登記證/護照號碼                   與被保險人關係         

□ 順位 □ 比例   %

姓名(英文)-須與護照相同 商業登記證/護照號碼                   與被保險人關係         

4. □

職業內容變更

公司名稱                                 行業或公司業務性質 職業                           工作內容              

5. □

保單補 發

□ 遺失

□

毀損 原保單因前述原因特申請補發，倘日後發現原保險單，應予作廢，併此聲明。

(請繳交工本費美金 25 元)


6. □

復效

兹聲明本保險單在停效期間確未發生任何事故，並同意依保險單條款有關契約效力的恢復申請復效。要保人須提供可保證明，並獲得本公司同意。

7. □

變更基本保費

每年繳付             美元

8. □

現金提領

提領金額              美元

※付款方式：▇匯款至以下帳戶(限要保人帳戶)

受款銀行國別：                       受款銀行 SWIFT CODE： 受款銀行名稱： 受款銀行帳號：                         

其他及補充說明：

就申請 FATCA 產品，本人／x等作為保單要保人，現聲明本人／x等明白和同意：

1. 英屬百慕達商安達人壽保險股份有限公司國際保險業務分公司（「貴公司」）有責任遵從本地及/或外國的監管，稅務，立法或司法機構，包括但不限於台灣稅務單位及美國稅務局（以下簡稱「官方機構」）所頒布及不時修訂的法例，條例或指令(「規定」)。

2. 貴公司將在本人／x等提出申請本保單（此乃向本人／吾等繕發保單的條件）時及在本保單期間不時：－(i) 要求保單要保人、受益人、繼任持有人及/或實際受益人提供其個人資料，保單資料及其他證明文件並填寫額外的表格；及(ii)向有關官方機構，包括但不限於美國稅務局及台灣國稅局，報告及/或披露保單要保人、受益人、繼任持有人及/或實際受益人的資料，保單資料及/或其他額外資料（統稱「資料」）以遵從規定。

3. 若本人／x等的資料出現任何變動，本人／x等會立即通知貴公司，並且按照貴公司之要求填寫額外的表格，及提供額外資料和文件，以證明該項變更；

4. 若保單要保人、受益人、繼任持有人及／或實際受益人發生改變，本人／吾等會立即向貴公司提供新的保單要保人、受益人、繼任持有人及/或實際受益人之資料及其相關文件；本人／x等亦明白此乃貴公司同意有關改變的先決條件；

5. 本人／x等同意貴公司可就向本保單帳戶支付或收取的款項中扣除並預扣貴公司根據規定下必須預扣的美國稅項（預扣稅），並將該預扣稅上繳美國稅務局以履行 規定，及

6. 本人／x等在本保單下對受益人、繼任持有人及/或實際受益人的資料須負有義務時，本人／吾等將盡最大努力使他們就其資料遵守相同的義務，包括直接向貴公司提供其資料和相關文件，並向貴公司給予他們的同意，以向官方機構披露及轉移他們的資料，以及按規定扣除和持有其預扣稅並上繳美國稅務局。本人／x等亦同意 貴公司可為此直接聯絡受益人、繼任持有人及/或實際受益人。

同意向第三方披露資料，本人／x等作為保單要保人，現聲明本人明白及同意：

1. 貴公司使用、處理、儲存、披露、轉移貴公司向本人／x等收取之任何資料、保單資料及任何包含本人／x等的個人資料的政府/官方文件及表格予貴公司隸屬同一集團之其他公司（「集團公司」）及/或官方機構以遵從規定；及

2. 根據此聲明的要求下，本人／x等有責任提供最新、準確及完整的資料，以作為該保單申請/更改要求之先決條件。


業務員簽名：           


要保人簽名：                     被保險人簽名：        


新要保人簽名：           

※變更要保人時，新舊要保人需同時簽署，要/被保險人變更姓名或變更簽名樣式，須同時簽署變更前後之簽章。


要保人商業登記證/護照號碼：                聯絡電話：      


法定代理人簽名： 申請日期： 年 月 日

(要、被保險人如未成年，須法定代理人一併簽名。)


登錄證號：            


聯絡電話：            


單位/分行主管：          

簽署人章：


Policy Service Application Form (OIU)


Policy number

Policy Owner

Insured

Following changes of this application form will be part of the original policy, which agreed and signed by Chubb Tempest Life Reinsurance Company Ltd., Taiwan Offshore Insurance Unit Branch and the policy contents will be the following:

1. Change of address and contact number

□ Residence address

□ Permanent residence

address of policy

owner

□ Change of contact

number

□ Residence address □ Change all policy owners’ insurance policies

Residence country                      Address              

□ Permanent residence address of policy owner □ Same as contact address


□ Change of contact number

Home number          Office number           Cell number        

2. Change of policy owner/successor owner

□ Change of Policy owner

□ Change of Successor

□ Policy owner □ Successor owner English name correspond with passport       

□ Policy owner □ Successor owner Chinese name     Relationship with Insured       

Business registration certificate/passport number      

Date of birth Sex                    Place of birth             _ Nationality                Residence country Home number               Office number Cell number                 E-mail           

Company name                                     Industry of the company                                Occupation                            

Job Description                           

□ Policy owner □ Successor owner owner residence address            

□ Policy owner □ Successor owner owner permanent address           

1. After the policy owner has change, I declare(new policy owner) I will taking all rights and obligations from this policy, if there are any disputes, I will taking all legal responsibilities and there are nothing relate to your company.

2. If this policy renewal payment is using credit or financial institution, the new policy owner needs to fill in the authorization letter for insurance premium again.

3. Please attach the following documents: 1. Declaration letter of FATCA 2. New policy owner I.D. documents

4. Please attach the proof of residence for verification purpose, and also including utility bills within three months when you sign the policy form, such as electricity bill, phone bill and etc….

3. Change of death beneficiary

※ Do not specify heir apparent.

※ Total share percentage must be equal to 100%.

□ Cis-Position   □ Proportion   %

English name-same as passport                          Business registration certificate/passport number               

Relationship with insured           

□ Cis-Position   □ Proportion    %

English name-same as passport                   

Business registration certificate/passport number                 Relationship with insured           

□ Cis-Position   □ Proportion    %

English name-same as passport                          Business registration certificate/passport number                 Relationship with insured           

4. □ Change of Job Content

Company name               Industry of the company              Occupation                   Job Description          _      

5. □ Policy Reissue

□ Lose □ Damage

I declare that due to the above reason so apply for policy reissue is necessary; once the original policy is found, the original policy is no longer valid. (Please submit US$25 for Administration Fee.)


6. □ Reinstatement

I declare that I have not involve in any accident, during the temporarily suspend of the insurance policy period, and I have agreed that I will be apply for the reinstatement of insurance policy’s term and relate clause.

7. □ Amount

Yearly payment             US dollar

8. □ Xxxx withdraw


Withdraw amount              US dollar


※Payment method：▇Transfer to following account (only policy owner’s account)

Country of bank：                    SWIFT CODE：         

Name of bank：                                       Bank account：                           

Description：

Applied FATCA product, I/WE, the Owner(s), declare that I/We understand and agree that:-

1. Chubb Tempest Life Reinsurance Ltd., Taiwan Offshore Insurance Unit Branch (the “Company”) is obliged to comply with the laws, regulations or orders (the “Requirements”) of local and/or foreign regulatory, tax, legislative, or judicial authorities, including but not limited to, the Inland Revenue Department of Taiwan and the Internal Revenue Service of the United States of America (the “Authorities” and each an “Authority”) as promulgated and amended from time to time;

2. When I/We apply to take out the Policy, as a condition of its issue to me/us, and from time to time during the term of the Policy, the Company will:- (i) request the owner(s), the beneficiary, the successor owner and/or the beneficial owner of the Policy to provide his/her personal data and supporting documents and to complete additional forms; and (ii) to comply with the Requirements, report and/or disclose to the applicable Authorities data regarding the owner(s), the beneficiary, the successor owner and/or the beneficial owner of the Policy, Policy information and/or additional information (collectively the “Information”) including, but not limited to, the Internal Revenue Service of the United States and the Inland Revenue Department of Taiwan.

3. I/We will immediately update the Company if any change of the Information and complete additional forms and provide additional information and documents at the Company request in support of the change;

4. Where there is a change in the owner(s), the beneficiary, the successor owner and/or the beneficial owner of the Policy, I/We will immediately provide to the Company the data and supporting documentation for the new owner(s), beneficiary, successor owner and/or beneficial owner and I/We understand that it is a pre-condition to the Company’s agreeing that change;

5. I/We consent to the Company’s deducting and withholding the tax as required to withhold under the Requirements from payments made to or from the Policy account and remitting this to the Internal Revenue Service of the United States of America (“IRS”) to comply with the Requirements; and

6. Where I/We have an obligation under the Policy with respect to information relating to the beneficiary, successor owner and/or beneficial owner, I/We will use my/our best endeavors to procure that they will comply with that obligation with regard to their data including providing to the Company directly that data and supporting documentation and giving the Company their consent to the disclosure and transfer of that data and supporting documentation to the Authorities and deducting and withholding the tax as required to withhold under the Requirements and remitting this to the IRS. I/We further agree that the Company may contact the beneficiary, successor owner and/or beneficial owner directly for these purposes.


Consent to disclose information to third party I/WE, the Owner(s) further understand and consent that:

1. any Information, Policy information and governmental/official documents and forms received from me/us containing my/our personal data collected under the Policy by the Company are provided and may be used, processed, stored, disclosed, transferred by the Company to the companies within the group of which the Company is a subsidiary (the “Group Companies”) and/or to any of the Authorities for the compliance of the Requirements; and

2. I/We am/are obliged to supply update, accurate and complete information as required under this FATCA declaration and this is a condition precedent for me/us to

apply the Policy/request for change thereof.


Clerk signatur：            Register number：           Contract number：        Unit/Branch manager：       Signatory stamp：


Policy Owner signature：        


Insured signature：          


New Policy Owner / Successor Owner signature：           


※Both new and old policy owner should sign concurrently when changing the policy owner. When policy owner /insured change their name or signature, both old the new one should sign concurrently.

Policy owner business register certificate/Passport：            Phone number：        

Legal Guardian signature：           

※Legal Guardian require to sign on the application when insured or policy owner under 20.


Apply date：     year      month      day

Document Metadata

Filed: September 26th, 2016