Project insurance form

II. Comments

Special instructions, if any: (subject to approval under the Company’s guidelines)

Reason for the request:

Declarations

(a) I understand that Coverage and / or Payment under the insurance contract will not be made if: (i) the policyholder, insured, or person entitled to receive such payment is residing in a sanctioned country; or (ii) the policyholder, the insured or person entitled to receive such payment is listed on the Office of Foreign Assets Control (OFAC) Specially Designated Nationals (SDN) list, the OFAC Sectorial Sanctions Identifications list or any international or local sanctions list; or (iii) the payment is claimed for services received in any sanctioned country. I also understand that the Company shall not be liable to pay any claim or provide any coverage or benefit to the extent that the provision of such coverage or Benefit would expose the Company to any sanction under any applicable laws.\n\n(b) I hereby grant VANDE-LANOTTE, acting as intermediary representing ALLIANCE ASSURANCE, my consent to process, share and transfer my Personal Data inside or outside this country to ALLIANCE ASSURANCE and, where necessary, their authorised representatives, reinsurers, service providers, business partners or any lawful assignee, novatee or transferee. Such processing, sharing or transfer shall be for handling this application, administering the policy, performing the respective obligations of the insurer and its representative, or complying with applicable legal obligations.\n\n*Personal Data means all information relating to me (whether marked personal or not) disclosed to VANDE-LANOTTE by whatever means either directly or indirectly which concerns, including but not limited to, my medical conditions, treatments, prescriptions, business, operations, contact details, account balances / activities or any transactions undertaken with VANDE-LANOTTE.\n\n(c) I hereby authorize VANDE-LANOTTE to send me notifications and notices via short message service “SMS” and I accept receiving SMS and understand that VANDE-LANOTTE makes no warranty that the SMS will be uninterrupted or error free.

U.S.A. Internal Revenue Serviço (IRS) declaration:

In submitting and in signing this form, the applicant(s) certify(ies) that the Insured, Joint Insured, Applicant, and any designated Beneficiary(ies):

United States persons for United States (U.S.) Federal Income Tax purposes.

Foreign Account Tax Compliance Act (FATCA) declaration:

The Insured / Owner consents to VANDE-LANOTTE, its officers and agents disclosing any Confidential Information to: (i) ALLIANCE ASSURANCE and authorised representatives of VANDE-LANOTTE and ALLIANCE ASSURANCE in any jurisdiction; (ii) any persons as required by law (including but not limited to the U.S.A. Foreign Account Tax Compliance Act) or authority with jurisdiction over any of the Permitted Parties; (iii) professional advisers, insurer, reinsurer or insurance broker and service providers under a duty of confidentiality; (iv) any actual or potential assignee, novatee or transferee in relation to any of ALLIANCE ASSURANCE’s rights and / or obligations under this Policy. ALLIANCE ASSURANCE will deduct any withholding required by FATCA and may request appropriate documentation concerning the Insured / Owner’s US or non-US status.

The Insured / Owner consents to VANDE-LANOTTE, its officers and agents disclosing any Confidential Information to: (i) ALLIANCE ASSURANCE and authorised representatives of VANDE-LANOTTE and ALLIANCE ASSURANCE in any jurisdiction; (ii) any persons as required by law (including but not limited to the U.S.A. Foreign Account Tax Compliance Act) or authority with jurisdiction over any of the Permitted Parties; (iii) professional advisers, insurer, reinsurer or insurance broker and service providers under a duty of confidentiality; (iv) any actual or potential assignee, novatee or transferee in relation to any of ALLIANCE ASSURANCE’s rights and / or obligations under this Policy. ALLIANCE ASSURANCE will deduct any withholding required by FATCA and may request appropriate documentation concerning the Insured / Owner’s US or non-US status.

CRS Individual tax residency Self-Certification declaration:

The Common Reporting Standard (CRS) is a tax information exchange standard developed by the Organization for Economic Co-operation and Development (OECD) and approved on 15 July 2014. Please complete the following table indicating (i) where the Account Holder is tax resident and (ii) the Account Holder’s Tax Identification Number (TIN) for each country/jurisdiction indicated. If a TIN is unavailable, enter reason A, B or C: A - the country/jurisdiction does not issue TINs to its residents; B - the Account Holder is otherwise unable to obtain a TIN (please explain); C - no TIN is required under domestic law.

I understand that the information supplied by me is covered by the full provisions of the terms and conditions governing the Account Holder’s relationship with VANDE-LANOTTE setting out how VANDE-LANOTTE may use and share the information supplied by me. I acknowledge that the information contained in this form and information regarding the Account Holder and any Reportable Account(s) may be provided to the tax authorities of the country/jurisdiction in which this account(s) is/are maintained and exchanged with tax authorities of another country/jurisdiction pursuant to intergovernmental agreements to exchange financial account information. I certify that I am the Account Holder (or am authorized to sign for the Account Holder) of all the account(s) to which this form relates.

Declaration:

I declare that all statements made in this declaration are, to the best of my knowledge and belief, correct and complete. I undertake to advise VANDE-LANOTTE of any change in circumstances which affects the tax residency status identified in this application, or causes the information herein to become incorrect or incomplete, and to provide a suitably updated self-certification and Declaration, within 90 days of such change in circumstances.

E-mail Declaration:

By providing your E-mail address and signing this application you agree to receive the policy document, certificate and / or any other documents (“Documentos”) via electronic mail (“E-mail”). Please be aware that having chosen this electronic delivery of Documentos, it is your responsibility to ensure that the E-mail address you have provided us is correct at all times. VANDE-LANOTTE is not responsible for non-receipt of E-mails due to invalid E-mail addresses or other technical problems related to your E-mail service. If you would like to change your E-mail address with VANDE-LANOTTE, or if you would like a paper copy of the Documentos, please notify us immediately. By signing this application, you understand and agree that if you wish to discontinue receiving Documentos electronically it is your obligation to revoke this Authorization by another written document.