美商安达产物要求变更保单表格(英文版)(8页).pdf
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Please tick appropriate box(es) for
request 5 New Request 5 Reply
Policy Number: Full Name of Insured:
* Full Name of Policyowner:
In compliance with the Anti-Money Laundering
and Counter-Terrorist Financing (Financial
Institutions) Ordinance and the Guideline on
Anti-Money Laundering and Counter-Terrorist
Financing which is issued by the OKce of the
Commissioner of Insurance as amended from
time to time and to comply with industry guidelines,
Chubb Life Insurance Company Ltd. is required to
review customer identity information
to ensure they are up-to-date and relevant. You
are required to complete the relevant section(s)
below if (i) there is any change of customer
identity information provided in the original
policy application, any subsequent change of
policyowner identity information you made
previously, or you have become an US citizen
or resident in US for tax purpose; or (ii)
you wish to provide Chubb Life Insurance Company
Ltd. your US-related status (e.g. place of birth,
citizenship and residency). By completing this
form, you may also be required to provide the
identity information and original identiUcation
documents proof, and if necessary, the appropriate
US tax form(s) for identiUcation, veriUcation
and further assessment.
1. Change of Personal Information
5 Insured
5 Policyowner
(Please give documentary proof for
Insured/Policyowner e.g. copy of HKID