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. Page 1 of 2 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 Page 2 of 2