Application form. Pension application form. Individual Please fill in completely and check where applicable. Please write in block letters (print).

Transcription

1 Pension application form Employer/employee Policy number: Individual Please fill in completely and check where applicable. Please write in block letters (print). Application form Employer/ Policyholder a. Name b. Legal form c. Address d. Nature of industry e. Sector of industry f. Contact person g. Job title contact person h. Telephone number contact person i. address contact person j. Telephone number k. address 2. Employee = insured (Please specify names in separate enclosure if applying on behalf of multiple insured) a. First name b. Name c. ID number d. Director-shareholder e. Date of Birth f. Gender g. Nationality h. Marital status i. Name/initials spouse/partner j. ID number k. Date of birth l. Names and birthdates of children m. Address n. Telephone number o. Island p. Occupation(s) q. Nature of work 3. Insurance a. Cover b. Start date insurance a. b. c. d. e. f. g. h. i. j. Nature of business: k. 2. a. b. c. Passport Driver s License ID d. e. f. Male Female g. h. Unmarried Formerly married Married, to Widow / widower Living together, with i. j. Passport Driver s License ID k. l. Name Date of birth Gender m. n. o. Curaçao Aruba Bonaire St. Maarten p. q. 3. a. b. Pension insurance employer/employee Pension insurance individual only Tax clause Pension clause Blocking clause Reinsure death risk? (Guardian Group Fatum as self-administrator) as specified in page 3 of present form under Pension commitment.

2 c. End date insurance d. End date premium payment c. d. 4. Premium waiver in case of invalidity (I.S.) Invalidity pension (I.R.) 5., in the amount of: 6. Premium* 6. Premium Per year 6 months 3 months month Lump sum premium 7. Premium payment 7. Via broker Direct to insurance company Direct debit ** Other, namely Authorization The undersigned hereby authorizes the company, until further notice, to debit the insurance premium directly from the bank account the details of which are specified hereunder. Signature of accountholder Bank / financial institution: Account number: * ** Definitive premium to be determined by insurance company If payment occurs via broker, please sign the requisite authorizations as shown. 8. Transfer of equity This application is to commute insurance policy(ies) If so, which policy number(s) The premium due for this/these policy(ies) has been remitted until, Appointment of beneficiaries For the portion of the insured benefit and any profit bonuses covering: - The old-age pension: insured; - The widow/widowers/partner pension; - The afore-mentioned spouse/partner; - The orphan s pension: all pension entitled children; - Disability annuity insured. 9. For any moneys remaining: The insured 2. The afore-mentioned spouse / partner 3. The insured s legal heirs (first degree) 4. The (former) employer

3 10. Death risk Has life cover been taken on the insured s life, at any time in the past few years? If so, with which company(ies)? 10. Is life cover being applied for, or has life cover been applied for elsewhere on the life of insured? If so, with which company(ies)? For how much? (In each case)? For how much? (In each case)? Application form If the sums insured under above policy(ies) combined with the insurance cover presently applied for would amount to, or exceed ANG AWG ,- USD 84,000.-, a further medical examination of the candidate-insured will be required. Death risk in this context means the risk covered, and the sums insured as of the start date of the insurance agreement as stated in the relevant policy schedule(s). te: The assessment of the totality of the death risk is the insurer s prerogative. If the insured dies within 10 years after the start date of this insurance, a reassessment will take place to determine the accuracy of the information provided on behalf of this application. Where evidence to the contrary should be revealed the insurer shall be authorized to withhold any benefit(s) for which this policy was secured. Signed at, Signature of policyholder Signature of employee Signature + company seal of employer: Details insurance broker Name insurance broker: Medical examination schedule with doctor Account Manager Signature

4 Pension entitlements By answering the questions below as accurately as possible, you will enable us to: - prepare an accurate pension estimate; - provide a pension letter that is as complete as possible; - process your application correctly. Pension plan Pension date Date on which the employment commenced Annual earnings Holiday pay Other fixed salary components ( x monthly) Annual income Deductible AOV (General Old-Age Pension) Pension base a. Pension entitlements based on salary / service years Percentage per service year: % O.A.P W P ( % of O.A.P) W.O.P ( % of W.P. ) To year (covered by annuity capital) b. Projected pension amounts O.A.P at pension date: Wi.P. at pension date: Wd.P. before pension date: W.O.P. before pension date: c. Projected target capital Target capital, based on % upon decease 1st year upon decease final year when alive at end date d. Capital / annuity to be insured Rate: Amounts: e. Self-administration: Risk cover only WP WOP Tariff scale 20 Tariff scale 20-D f. Index Pensions after pension date: indexation % Before pension date: WP/WOP indexation % g. Defined premium including IS-surcharge excluding IS-surcharge Fixed premium on year basis: Premium as percentage of pension base % Premium as a percentage of annual earnings % Maximum contribution (statutory) Single lump sum: per: Final salary scheme Average earnings scheme Combination final salary / average earnings up to age Defined Premium Plan 2. Disability pension a. 70% 80% % of salary b. B Same as Old-Age Pension Employer pays % of the premium

5 U.S. Indicia As of July 1st 2014, all fi nancial institutions are required by law according to the Foreign Account Tax Compliance Act (FATCA) to provide the IRS (U.S. Tax Authorities) with information about customers who could have tax obligations in the United States of America. As of 2015, Guardian Group Fatum forwards this information to the IRS. For more information on FATCA please visit U.S. Indicia INDIVIDUAL CUSTOMERS US Indicia Please check all those that apply: U.S. citizenship (passport) or lawful permanent resident (green card holder) 2. U.S. birth place 3. U.S. address (residence, correspondence, or P.O. Box) 4. U.S. bank account or directions received regularly from U.S. address 5. U.S. telephone number 6. Only address on fi le is in care of or hold mail address or U.S. P.O. box (excl. foreign P.O. Box as U.S. indicia) 7. Power of Attorney or signature authority granted to person with U.S. address U.S. Indicia LEGAL ENTITY Please check all those that apply: Are you a legal entity incorporated or formed in the U.S.? 2. Does your company have a U.S. registered offi ce or major place of business address in the U.S. 3. For Corporations: Does the Corporation have major shareholders, i.e. individual(s) who own 10% or more of the company, that are U.S. citizens or U.S. residents? 4. For Partnerships: Are one or more of the partners U.S. citizens (passport) or lawful permanent resident (green card holder)? 5. Are you a Financial Institution? If so, please provide the GIIN number. Provide information where applicable and provide copies (or scans of the document via indicia@dc.myguardiangroup.com) Provide information where applicable and provide copies (or scans of the document via indicia@dc.myguardiangroup.com) I hereby declare that none of the above is applicable. I hereby declare to have received and read the U.S. Indicia and that all information provided in this application and in documents submitted is true and correct. Signature: Date: Full name: Identifi cation or Passport number:

6 Ascertaining and verifying your identity Within the framework of national and international legislation and regulations, such as the prevention of money laundering and fi nancing of terrorism and the Offi ce for the Disclosure of Unusual Transactions, Guardian Group, and its affi liated companies such as Fatum Holding N.V., Fatum General Insurance N.V., Fatum General Insurance Aruba N.V., Fatum Health N.V., Fatum Life N.V. and Fatum Life Aruba N.V. (hereinafter referred to as: Guardian Group ), in its capacity of insurer (fi nancial service provider), is obliged to verify your identity. This enables us to establish whether the identity you have given us matches your true identity. The aforesaid means that Guardian Group will ask you, regardless of you being a private or business client, to identify yourself by means of valid ID/original documents, prior to providing you with a service or entering into a business relationship with you. Subsequently, Guardian Group will make clear (color) copies of your valid ID/original documents and arrange for you to sign and date these copies. These copies are deemed to form an integral part of your request and will be fi led in the dossier held by Guardian Group, together with this form. Any personal data will be stored by us in the Guardian Group client administration. The various regulators will ensure that Guardian Group, in its capacity of insurer and fi nancial service provider, will correctly and properly meet and fulfi ll its statutory obligations with regard to ascertaining and verifying your identity and, if (legally) required, the disclosure of personal data to third parties. The applicable diagram below is to be completed by a Guardian Group staff member or a Guardian Group intermediary. Valid IDs in the event of natural persons and/or executive legal persons* Policyholder Insured Premium contributor Beneficiary Number Rnwl date Number Rnwl date Number Rnwl date Number Rnwl date ID card (sédula) or Driver license or Passport (*) A copy of an (expired) ID card (sédula), driver license or passport is not accepted as valid ID. Original documents in the event of legal entities Policyholder Insured Premium contributor Beneficiary a) Extract from the Commercial Register of the Chamber of Commerce** and, among other things, b and c: b) Articles of Association and c) Shareholders register /no /no /no /no /no /no /no /no /no /no /no /no (**) A copy of an extract for the Commercial Register of the Chamber of Commerce and/or older than six (6) months is not accepted as an original document. (/no) Delete as appropriate. To be completed by a Guardian Group staff member or a Guardian Group intermediary: I (full surname and fi rst name of Guardian Group staff member or Guardian Group intermediary***), herewith declare that I have accepted the original and valid ID/original documents referred to by me in the above diagrams, and that I have made clear (color) copies from these, which copies are deemed to form an integral part of the client s request and which will be added by me to the Guardian Group dossier. Country : Date : Signature : (***) Delete as appropriate. ARUBA L.G. Smith Boulevard 162 P.O. Box 510 Aruba Tel.: (297) Fax: (297) BONAIRE Kaya Gobernador N. Debrot 35 P.O. Box 152 Bonaire Tel.: (599) Fax: (599) CURAÇAO Cas Coraweg 2 P.O. Box 3002 Curaçao Tel.: (599-9) Fax: (599-9) SINT MAARTEN A.J.C. Brouwers Road 6 P.O. Box 201 Sint Maarten Tel.: (1-721) Fax: (1-721)