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新保單持有人/受抵人補充陳述書 - 適用於《海外帳戶稅收合規法案》 Supplementary Information Form For New Policyholder/Assignee - Applicable to Foreign Account Tax Compliance Act (FATCA) 受保人姓名 保單編號 Name of Insured Policy No. 新保單持有人/受抵人姓名 Name of the New Policyholder/Assignee 本人(等)謹此代表本人(等)及所有受保人聲明及同意 (1) 以下一切陳述，不論是否本人(等)所寫，就本人(等)所知所信均屬真確及事實之全部； (2) 以下一切陳述，將成為更改保單的根據，並作為保單一部份。倘日後發現與事實不符，即使更改申請已簽發亦可能將導致批註及/ 或保單失效。 I/WE HEREBY DECLARE AND AGREE on behalf of myself/ourselves and the proposed insured person(s) that (1) all statements and answers whether or not written by my/our own hand are to the best of my/our knowledge and belief, full, complete and true; (2) all answers to such questions, together with this agreement, shall form the basis for policy change and become a part of the policy. For discrepant statements found by the Company in future, the Company may void the Endorsement and/or the policy even if the policy change has already been approved and issued. 新保單持有人/受抵人之個人資料 Personal Information of New Policyholder/Assignee 1 請提供 閣下的出生國家。 Please provide your Country of Birth. 2 閣下是否美國公民或美國稅務居民(見備註)？若「是」，請填妥並遞交 W-9 □ 是 Yes 表格或等同文件。 納稅人識別號碼 TIN No. : ____________________ Are you a U.S. Citizen or a U.S. tax resident (see Notes)? If “Yes”, please complete Form W-9 or an equivalent form. □ 否 No 3 閣下是否代表其他人士提出此投保申請? 若「是」，請提供詳情。 □ 是 Yes (請提供詳情 Please provide details) Are you acting on behalf of another person in making this application? If “Yes”, please prov