Business Information Form

Transcription

1 Head Office One Westmount Road North P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7 TF T Fax Business Information Form Applicant/Owner (first, last) Application/Policy Number This form must be completed when the owner of the policy is a business or organization. Please complete all applicable sections. 1. ENTITY IDENTIFICATION Please complete the applicable section: a) Corporation b) Sole Proprietor/Partnerships/Associations/Unions c) Not For Profit Organization d) Estate or Trust Complete the following information for all trustees, beneficiaries and executors/settlers of the Estate or Trust: a) corporation Full Legal Corporate Business Identification Number or Quebec Enterprise Number Incorporation Number Date of Incorporation (dd/mm/yyyy) Jurisdiction (federal/provincial) City Province Postal Code Address Describe principle business activity (if a holding company, describe the nature of businesses held) Do you carry on business under any other names? Please list: I have attached the following documentation: (you are required to choose at least one for (a) and (b) a) Evidence of existence (choose at least one): q a copy of articles of incorporation q business license q registration of business name or corporate search b) Evidence of power to bind (choose at least one): q bylaws q corporate resolution q certificate of incumbency q other List the name(s) of the corporation s directors: 594(2014/07/01) Page 1 of 7

2 Business Information Form 1. ENTITY IDENTIFICATION (CONTINUED) b) SOLE PROPRIETOR /PARTNERSHIPS/ASSOCIATIONS/UNIONS Full of Entity Business Identification Number or Quebec Enterprise Number Incorporation Number (if applicable) Date of Incorporation (if applicable) (dd/mm/yyyy) Jurisdiction (federal/provincial) City Province Postal Code Address Describe principle business activity (if a holding company, describe the nature of businesses held) List the name(s) of the organization s principles/directors: Please attach as applicable: q Sole Proprietor and Partnership: Copy of business license or registration of business name (Not required if name of company is the exact name of the proprietor) q Association: Copy of the bylaws, regulations, association agreement/nominate contract (PQ) q Union: Copy of most recent collective agreement q Limited Liability or Other Corporation: Articles of incorporation c) NOT FOR PROFIT ORGANIZATION (Incorporated or Non-Incorporated) Full of Not for Profit Organization Incorporation Number (if applicable) Date of Incorporation (if applicable) (dd/mm/yyyy) Jurisdiction (federal/provincial) City Province Postal Code Address Describe principle business activity (if a holding company, describe the nature of businesses held) I have attached one of the following (if applicable): q a copy of articles of incorporation q business license q registration of business name or corporate search Does the organization solicit public contributions? q Yes q No List the name(s) of the organization s directors: Is the organization registered with Canada Revenue Agency? q Yes q No If yes, Registration Number 594(2014/07/01) Page 2 of 7

3 Business Information Form 1. ENTITY IDENTIFICATION (CONTINUED) d) ESTATE OR TRUST Complete the following information for all trustees, beneficiaries and executors/settlers of the Estate or Trust: Select as applicable: Address Detailed occupation I have attached evidence of existence (choose at least one): q Trust Agreement/Deed q Will/Estate Documents 2. beneficial ownership A beneficial owner is anyone who owns 25% or more of the business/entity. Complete the following for each beneficial owner. q No person owns 25% or more of the above business/entity. (first, middle initial, last) Residential City Province Postal Code (first, middle initial, last) Residential City Province Postal Code (first, middle initial, last) Residential City Province Postal Code If you were unable to provide the information for any of the shareholders, please explain why: 594(2014/07/01) Page 3 of 7

4 BUSINESS INFORMATION FORM 3. IDENTITY VERIFICATION Use this section to verify the identification of the individual(s) who have the authority to sign or provide direction on behalf of the corporate/non-corporate entities for the above application/contract number. Provide ONE current/original Canadian government issued photo ID (e.g. driver s licence, passport, citizenship card or permanent resident card). If not available, provide TWO other identification documents (e.g. birth certificate and one of the following: foreign passport, employee ID card, SIN card, credit card, or provincial health card (except for ON, MB and P.E.I.). (first, middle initial, last) Address Detailed occupation (first, middle initial, last) Address Detailed occupation (first, middle initial, last) Address Detailed occupation 594(2014/07/01) Page 4 of 7

5 Entity includes a corporation, trust, partnership, association or other organization. BUSINESS INFORMATION FORM FATCA means the United States of America (U.S.) Foreign Account Tax Compliance Act. Canada has an Enhanced Tax Information Exchange Agreement (Agreement) with the U.S. and reporting Canadian financial institutions must identify and report specific types of accounts. For information about the agreement, visit We will use the information provided in this form to determine our tax reporting requirements. Depending on the entity s FATCA classification, we may report to the Canadian Revenue Agency (CRA). 4. INTERNATIONAL TAX ENTITY CLASSIFICATION Instructions: The terms used in this section are defined in the Agreement. For more information on classifying the entity, consult with the entity s tax or other advisor, or view For tax reporting purposes, what is the FATCA classification of this entity? q U.S. person q Specified U.S. person. Provide U.S. Federal Taxpayer Identification Number (TIN). q Not a specified U.S. person Reason this entity is not a specified U.S. person q Non-financial foreign (non U.S.) entity (NFFE) q Active NFFE q Passive NFFE. Complete section 5 below. q Foreign (non U.S.) Financial Institution (FFI) Select the type of FFI below and provide Global Intermediary Identification Number (GIIN) if required. q Exempt beneficial owner. q Deemed compliant FFI. If registered, provide GIIN below. q Canadian financial institution. Provide GIIN below. q Other Partner Jurisdiction Financial Institution. Provide GIIN below. q Participating FFI. Provide GIIN below. q Non Participating Financial Institution. GIIN 5. INFORMATION ABOUT CONTROLLING PERSONS OF PASSIVE NFFE Instructions: This section must be completed for passive NFFEs. Other types of entities do not need to complete this section. q For trusts: Provide information below about every individual who is directly or indirectly, a beneficiary, settlor or trustee of the trust. q For any other Passive NFFEs: Does any individual directly or indirectly own or control 25% or more of the entity? q No If no, complete section 6. q Yes If yes, provide information about each of these individuals below. If you require more space, complete another form. 594(2014/07/01) Page 5 of 7

6 BUSINESS INFORMATION FORM 5. INFORMATION ABOUT CONTROLLING PERSONS OF PASSIVE NFFE CONTINUED First Middle initial Last name Is the individual a U.S. citizen or a U.S. resident for U.S. tax purposes? q No q Yes If yes, provide. First Middle initial Last name Is individual a U.S. citizen or a U.S. resident for U.S. tax purposes? q No q Yes If yes, provide. First Middle initial Last name Is the individual a U.S. citizen or a U.S. resident for U.S. tax purposes? q No q Yes If yes, provide. First Middle initial Last name Is individual a U.S. citizen or a U.S. resident for U.S. tax purposes? q No q Yes If yes, provide. 594((2014/07/01) Page 6 of 7

7 BUSINESS INFORMATION FORM 6. ENTITY APPLICANT/POLICY OWNER/OTHER ACCOUNT HOLDER DECLARATION AND SIGNATURES In this section, you and your mean the signing officers or trustees signing below. The Account Holder agrees to immediately notify us of any errors, omissions or changes in the information provided in this form, including any change in U.S. residency or citizenship status of a Controlling Person, or any change in the Account Holder s FATCA classification. By signing below, you confirm that: You are authorized to sign on behalf of the Account Holder. The information provided in this form is complete, current and accurate to the best of your knowledge. First Middle initial Last name Signature of signing officer or trustee Title Date (dd-mm-yyyy) First Middle initial Last name Signature of signing officer or trustee Title Date (dd-mm-yyyy) First Middle initial Last name Signature of signing officer or trustee Title Date (dd-mm-yyyy) 7. ADVISOR DECLARATION To the best of my knowledge, the information provided is complete and true. The identification details recorded match the valid and unexpired original identification shown to me in a face to face meeting. Advisor Signature Date (dd/mm/yyyy) Advisor Code Note: If you own this policy you can not sign as the advisor. If applicable, this declaration must be completed by another licensed and contracted advisor. 594(2014/07/01) Page 7 of 7