美商安达产物要求变更保单表格（英文版）（8页）.pdf

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