Zurich Global Choice Claim Form

Claim formGlobal ChoiceFor use when making a full encashment or a single one-off partial encashment. Before completingthis form please read all the notes at the end of this form carefully. Please complete all relevantsections fully, as incomplete information may delay the processing of the claim.Plan number1 Contact detailsWe adhere to strict confidentiality procedures when we communicate with our clients. For security purposes, we willregard the details you provide as your authorised contact details; it is therefore important that they are accurate andthat you let us know if any of these details change.Contact nameContact number(s)Fax numberEmail address2 Client detailsFor completion by individual planholders onlyFirst planholderTitleMr Mrs Miss MsSecond planholderTitleMr Mrs Miss MsDrOther – please give detailsDrOther – please give detailsFamily nameFamily nameForename(s)Forename(s)Please give details of any previous names used(including maiden name)Please give details of any previous names used(including maiden name)NationalityNationalityPassport no.Passport no.*If current residentialaddress is in the UAE,please also detail yourpermanent residentialaddress (if different).Current residential address*Current residential address*Zurich International Life

3UAE plans onlyIf you have fully encashed any other insurance plans within the last 12 months, either with Zurich or otherinsurers, please provide details in the space below.4 Options – please tick one onlyReason for cashing inAll encashment amounts are deducted in the plan currency.You can arrange for the encashment amount to be paid to you in the currency of your choice by completing theappropriate part of section 5 – Method of payment – on page 3.Option A Full encashment – this will terminate your entire planPlease note that a cash-in charge may apply.If you are making a full encashment, please return your plan schedule(s).If you have lost or misplaced your plan schedule(s), please complete the lost plan indemnity sectionon page 7.I have enclosed my original documentsI have completed the lost plan indemnity sectionOR, Option B Partial encashment across all fundsAmount (in plan currency)OR, Option C Partial encashment across specific fundsAmount (in plan currency)If you would like to sell from particular funds, please enter the full name of the funds, fund codes and whereapplicable the funds currency. To avoid any delays, please make sure that you write fund codes and fund names in fulland in CAPITAL letters.If you do not specify a percentage allocation we will make up the amount by cashing in the samepercentage value from each of the daily-priced funds in your plan.Fund code/currency Fund name (including name of fund management company) % of withdrawal amount(NOT % of fund value)’100%2

5 Method of paymentPlease note we are unable to make third party payments.*Please note that where the planholder is resident in the United States, you should provide details of yourUS bank account. If you do not have a US bank account please contact us for further assistance.Payments will be sent to you in the plan currency unless you specify otherwise:Payment currencyPlease tick one option only.Cheque BACS (UK only) Autopay (HK dollar in HK only)Telegraphic transferSingapore giro (SGD in Singapore only)For payments by chequeCheques are payable in sterling. However, if you are resident in Hong Kong, HK dollar, Japanese yen andUS dollar cheques are available. For claims submitted through our Middle East offices, UAE dirham andBahraini dinar cheques are available.Name of payeeResidential address*Please note that where the planholder is resident in mainland China, payments can only be made to a Hong Kongbank account.For payments by BACS/Singapore giro/Autopay (Sterling to UK banks/HK dollar to HK banks)Account holder’s name(s)Account numberBank sort code (UK only) – –Building society roll numberBank number (HK only)Branch number (HK only)Bank nameBank addressFor payments by telegraphic transferAccount holder’s name(s)Account numberBank nameBank addressBank sort code (UK only) – –Building society roll numberSWIFT codeIBAN number/ABA number(IBAN codes are recommended for euro payments)Reference to be quoted (if applicable)3

Method of payment (continued)Correspondent bank details (if funds are to be paid through a separate bank)Account nameAccount numberBank sort code (UK only) – –Building society roll numberSWIFT codeIBAN number/ABA number(IBAN codes are recommended for euro payments)Bank nameBank addressAdditional information for further credit6 Proof of identity and proof of residential addressFull proof of identity and address documentation may not be required in all cases. Please refer to your relevant financialprofessional or Zurich HelpPoint, who will confirm what documentation is needed for your case.Proof of identity for individual planholdersPlanholders and/or third party payors must provide one of the following valid primary documents that has beensuitably certified: (please tick to confirm which document is attached)Planholder 1 Planholder 2 Third party payor• Passport• Government issued ID cardProof of residential address for individual planholdersIn order to verify the planholder’s or third party payor’s current residential address, please attach either an original orsuitably certified copy of one of the following documents (the document seen must be less than three months oldupon receipt by us). The document must be issued in the name of the planholder or third party payor and show theaddress appearing on the form or held in our records as the current residence (please tick to confirm which documentis attached).Planholder 1 Planholder 2 Third party payor• Utility bill• Bank statement/Bank credit card statement• Letter from employer• Tenancy contract** This document does not need to be less than three months old – just valid and in date.If you have a P.O. Box address we will need either: (please tick to confirm which document is attached)Proof of payment for the box address (this must reference your physical residential address)ORA utility bill referencing your physical residential address4

6 Proof of identity and proof of residential addressIn certain circumstances, other forms of ID and/or address verification may be accepted for individuals.Your relevant financial professional should refer to the ‘Anti-money laundering checklist for personalbusiness’ (MSP2187), if you require further guidance.For corporate forms of ID and/or address verification, please refer to the ‘Anti-money laundering checklistfor corporate business’ (MSP2188).For the forms of ID and/or address verification for plans in trust, the trust company should refer to the‘Anti-money laundering checklist for trust business’ (MSP2189).All these checklists are available on request from your relevant financial professional or your localZurich office.For photographic documents‘I certify this to be a true copy of the original document and that the photograph is a true likeness ofthe holder.’For non photographic documents‘I certify that this document is a true copy of the original.’• Signature of certifier• Full name of certifier (in capitals underneath the certifier’s signature)• Position/job title• Company name, address, telephone number and email address• Date• FSA/HKCIB/PIBA/MAS/QFCRA registration number (if applicable)• Zurich International Life Limited appointed suitable certifier number (where applicable)• Details of the certifier’s regulatory/affiliate body and their reference numberDocument certification – all copy documents must be certified as true copies of the originals by a suitable certifierand must be certified with the wording above or we may require a new document completed in line with this guidance.Suitable certifiers will fall into one of the following categories:• A regulated introducer based in a recognised jurisdiction. Introducers not based in the UK, Hong Kong or Singaporeshould supply proof of their authorisation (including introducers registered by the FSA, HKCIB, PIBA, QFCRA and MAS);• An individual introducer who has been accepted as a suitable certifier by Zurich International Life Limited;• A notary public, lawyer, advocate or an embassy official (from the embassy of the country who issued the ID document);• French Maire (Mayor);• Commissioner of Oaths within a ‘recognised jurisdiction’ (verification of their professional status must be obtained);• Formally appointed member of the judiciary (excluding Justice of the Peace);• Accountant who is a member of a professional organisation, whose members are required to abide by anti-moneylaundering regulations, or who is regulated by a regulatory organisation;• Director/Manager of an authorised credit or financial institute in a ‘recognised jurisdiction’.5

10Claim form – guidance notes1 Returning your formPlease complete this form in CAPITAL letters andsend it to your relevant financial professional or toZurich International Life Limited, 43-51 Athol Street,Douglas, Isle of Man, IM99 1EF, British Isles.Telephone +44 1624 691111. Telefax +44 1624662038. If in Asia, our Hong Kong office at24/F One Island East, 18 Westlands Road, Island East,Hong Kong. Telephone +852 3405 7150.Telefax +852 3405 7268. Our Singapore office atSingapore Land Tower #29-05, 50 Raffles Place,Singapore, 048623. Telephone +65 6876 6750.Telefax +65 6876 6751. Or if in the Middle East,our Bahrain office at P.O. Box 10032, 19th Floor,Almoayyed Tower, Seef District, Kingdom of Bahrain.Telephone +973 175 63322. Telefax +973 175 64291.Our Dubai office at P.O. Box 50389, Al Mussalla Towers,Khaled Bin Al Walid Street, Dubai, United Arab Emirates.Telephone +971 4 397 4444 Telefax +971 4 397 4443.Our Qatar office at P.O. Box 26777, 404 Fourth Floor,Qatar Financial Centre Tower, West Bay, Doha, Qatar.Telephone +974 4496 7555. Telefax +974 4496 7556.2 Plans written in trustWe will make any cheque or transfer payable to all thetrustees. In some cases trustees may also authorisepayment jointly to themselves or to their professionalagent (e.g. a bank or solicitor).It is the trustees’ responsibility to ensure that theproceeds of the plan are used in accordance with theterms of the trust. Some trusts specifically exclude thesettlor (the person(s) who declared the trust) frombenefiting from the proceeds of the plan.3 Non-admittance of liabilityThe issue of this form does not imply admittance ofany liability to pay the claim by Zurich International Life.4 Cash-in optionsThere are three ways that you can take a single amountfrom your plan – please see below. The funds and theamount and currency required should be specified inthe options and payment method sections.Option A – full encashmentThere are alternatives to cashing in your plan andbefore deciding on the option you wish to take, werecommend that you take advice from your relevantfinancial professional. To close your plan we must sellall its fund holdings and deduct outstanding charges(as applicable) to obtain the final encashment value.Once we have received a full encashment instruction,you will not be able to reverse this decision, which willconstitute a full and final settlement of your plan withno further liability to Zurich International Life.Option B – cash-in across all fundsThis means that you take an equal amount across theplan to raise the amount required. The value of yourencashment will be deducted from all funds held.Option C – cash-in from specific fundsThis means you can specify which funds you would liketo deplete. If the value of the requested fund(s) isinsufficient to allow the withdrawal to take place, wewill need to obtain alternative instructions from you.This will lead to delays in providing you with theencashment amount.5 Cash-in chargeIf you make a partial encashment and the remainingplan value is less than USD15,000 or twice theoutstanding cash-in charge (whichever is the greater)then we will fully cash-in the plan, deduct anyoutstanding encashment charge or other charges andpay you the balance.If you fully cash-in during the first five years, or withinfive years of making an additional contribution, acash-in charge will apply which will be deducted fromthe value before payment is made to you. For additionalcontributions the cash-in charge will only apply tothose contributions made within the last five years.6 The effect of exchange rates and unit prices onclaim valueThe value of your claim will depend on the unit pricesapplicable on the date of payment. As exchange ratesand unit prices change daily, there may be a differencebetween your payment and any amount quoted atany earlier date.Zurich International Life Limited (Singapore branch) is authorised by the Monetary Authority of Singaporeto conduct life insurance business Singapore. Member of the Life Insurance Association of Singapore.Member of the Singapore Financial Dispute Resolution Scheme.Zurich International Life Limited is registered in Bahrain under Commercial Registration No. 17444.Zurich International Life Limited is authorised by the Qatar Financial Centre Regulatory Authority.Zurich International Life Limited is registered (Registration Number 63) under UAE Federal Law Number 6of 2007, and its activities in the UAE are governed by such law.MSP7039 (711039001) (08/10) RRDZurich International Life Limited provides life assurance, investment and protection products and isauthorised by the Isle of Man Government Insurance and Pensions Authority.Registered in the Isle of Man number 20126C. Registered office: 43-51 Athol Street, Douglas, Isle of Man,IM99 1EF, British Isles. Telephone +44 1624 662266. Telefax +44 1624 662038.Zurich International Life Limited is acting through its Singapore branch at Singapore Land Tower #29-05,50 Raffles Place Singapore 048623. Registered in Singapore No. F06754G.www.zurichinternational.comZurich International Life Limited is part of the Zurich Financial Services Group which has a representationin more than 50 countries.