Restart my policy payments URIC

a
Please use this form if you want to restart your regular payments.

please note that no changes to premiumr can be made where the poliry gwner i5 re5ident in the United States lncluding ahy
United States federally.ontrolled tertitory.
Please write clearly in CAPITAL letters and complete the form in English.

Policy number 8453972 Broker/Bank name

'1 Your Premiitm

Doyou want to change your premium amountf I l.lncrease regular premiu. f z Decrease regular premiu,n
I S.Nochaugu

Premium amount 100.00 Currency LKR Frequen(y MONTHLY

Month from whi.h regular premiums will re5tart

For UAE residents: lf you are tncreasing yoLir ptem um - please cornplete tlre
rr rurE
'Sour(e o, funds queslionnaire', applicable {or all poll(y
owners and add tional payor.

2 Your rl.:taiL

Pol r-y owner 1 Poli.y owner 2

Title tr lrl v.' [],' ritre I ,' 8," E,'
First name HALPANDENI HEWA First name

Last name SUDARSHI SENANI Last name

Preuous names or alias, in(luding marden name (if apdlcnb/e) Previous names or allas, including maiden name (il appllcable)

Nationality SRILANKAN National;ty

Do you hold nationality in another countryr f-l v", [] no oo you hold nationality in another (ountry? [ v* [ ruo

lf Yes', Lrlease coniirm the country ll 'Yes', please conliri-n the country

Are you a US* tax payer? Iv* p*" Are you a us* tax payer? [".' [ru"
AIe you a US* citizen? I v"r [] *" Are you a lJs* citizen? [ ]u,,, l-] ,',"

* The definition of US includes the 50 United states o, A,nerica, the District of Columbia, Guam, Puerto Rico, US Virgin lslands,
American Samoa and the Northern lvlariana lslands.
lf you have answered 'Yes'to any of the above que5tions, or if either policy owner is a US national, rerides in the uS or is
reiuesting a regular income pay;ent to be made to a US account, your appli(ation cannot be accepted by Zulich lnternational
Lite (Zuri(h).

Please state all (ountrie5 where you are (urrently deemed to be resident fol tax purposes

Country/Countries ol Tax reference number{s)i* Country/Countries o{ Tax rererence number(s)**

tax resideh(e tax residehce

** lf you are culrently tax resident in the United Kingdom, please provide your National lnsuran((} number'
Policy owner 1 Policy owner 2
Current residehtial address current regidential addrets
Sarre a5 policy owner I l*-] v", [--l No, please (onrplete the be]ow

Flat/villa nurnber 500 A tlat/villa number

Property/building name GRETNA HILL Property/bullding name

Area PEMLANDA Area

City RAGAMA City

country sRl LANKA Country

Corresponden<e address (lf different from residential address) Correrpondence address {rl clittelent 10m resirlenlrl 'tdLl'ess)
samc as porily owner ,l--] *t f-l \o plcascLorpetcInLD'low

P.O. Box number P.o. Box number

City City

Counfty Country

Additional details (il anY) Additional details (l/ aDY)

Mobile number Mobile number

code Country code Area code Phone number

[**-lr--l t---lt---*l
Country codo Area Phonc numbcr

6969969

Country of mobile number SRILANKA Countiy of mobile number

Email address SENANIHHSSC@Gl\ilAlL COM Email address

3 Your payment details

who will make the payments?
,additional payor - please (omplete the'change of payor form'
f eoti.y o*ne,' 1
f lolicy o*ner z [
Payment method (tick one only)
Credit card (Please provide a 'credit <ard mandate', available ln the method of pavment form)
[!:]
i= j oLrect debrt (DD)* (provrde a completed form {or'UAE DD'*, 'UK DD', 'singapote ciro'. UAEDD can be set up via onlirre bankinq)
Il
vislt your bank)
flL] Teleo,aohic transfer/Standinq order (please s-"t up via yoLrr onllne banking or

fL] l Cheoue'' Cllect!les mirjit lle md(ie payable to: 'Zurich lnternational Life Lirniled'
please pay any rnlssed prerniums via teleqraphic transfer or
* uAE DD can be set up for your credrt card or bank account in the uAE.
iheque. ueE DD will be used to collect the regular paymentt. olly: , ----. 6.
an,.r /r r<D1-t 65)
-lill'-i;,ir?j#l-'.iiffifi;.;;;;;;;rl,li urioi'r,". rusril=3.677s). Bahraini Dinar (usD1=0 3775) and Qatari
Rivar(usD1=3

4. Bank details
ordet o/ cheque'
For our reference, pfovide details of the bank account you will u5e for DD, telegraphi. transfer, standing

o..o,n. n,,0", r:l n r. l n r:-l u L-l u t-:l t-] |:] u t-] n Ll L l

IBAN

nnnnnnnnf nnnf Dnnmnf nntrnnnnnnInnnQ

5 Your investment detarls - Fill only fr:r restart of lapsed policy
l\,4oney Market funds. ll a new
For lapsed policyl Whcn a pollcy s lapsecl, any funds on thc policy will automati(ally be switched into thc
investm-.nt instru;tion is not received, youi polLy value and reguiai prenriums will be nv-"s1ed in th-" rnoney
narket {Lrnds until you advise trs

of your new investrnelrt strategy-

Please (hoose from one of the following options.
Optior - lnvert in my previous investment strategy
1
Thls is the lasl investment stralegy you have on your policy.

option - Automatic inYestment strategy (vi5ta/lnvestplus policy only)

2
I
What currency do you wanl the Als in? (f/ck one onlv) [ uso I GBP fl EUR

option 3 - My own thoice of funds

1l you would like to select more lunds please completc the 'Additional fuhd seledion form' and submit with thls request {orm-

Fuhd name (in.luding hame ol fund mahagemert (ompahy)

Please ensure the tolal adds uP to

6 Oriqin of wealth
lmportant intormation
guidelines' do(ument for Curnulalive
lf there are joint payors, we require orlgin of wealih ior both. Plea5e refer to the 'Origin of wealth
pr".*, f.*fr t"ilrii"q and new policle-s) above which we will require documentary evidence to supporl the iniolmation you are providinq below'

How the payor acquired the money

Savihgs from _in(ome/salary/ Additional payor
f;l Policy owner Policy owner 2 (if applicable)
L-J (ompanV prolrts/bonus 1

Employer's/Company's name CINNAIVON LIFE INTERGRATI

Employer's/Company's physical address 77 GALLE ROAD, COLOI,I8O

OO3OO SRI LANKA

Nature of company business HOTEL

lob title DIRECTOR, HOUSEKEEPING

Nu'nbe ol yea.s cmploycd with .ompdny 3I\4ONTHS

Number of years you have be-"n saving 18 IlIONTHS

Annual income (in USD) 50000

Eonus (in USD) 3000

f-l other (pro.eeds from shares/ Additional payor

Policy owner Policy owner 2 (if applirable)
L,--) investment holdings/propeny sale) 1

Please include full details of where funds

are from, dates, (urrency and amount

7 Your proof of identity and proof of residential address

The pcrlicy owne(s) tvtust provide a valid and certilied copy of their lD and proof of address'
Proo{ of Proof of residential address
. Passlrorl (opy - in(lLdi,t9 s.grlature page a'ld r Emirates lD (for UAE residents ar)d passport (opy rYlust be provided
residence visa (expats) ds p'oo1 o' lD)
. Government issqed identity card (both sides) . Utility billlletter froflr ernployer (les5 than tt,lC" q9$l"-SlQ.
(Stnaapore.dpntitV (ard dnd 5r,'rq;lpo,e arn'ed . A valid tenancy/lease contract, or
force> lDr.ard cdn be used for both proof oi
lD and residential address)
; Brh,*1 Cf'R hf. ,l*"t
tt* ,,crslomer,s guide to AML" for further information on proof of lD, proof of address and certificatlon of clpy documents'
I"u.a *tu, to

3
 B Llnderwriting requirements to restart (for policies with insurance benefits only)
Please.omplete the'Reinstatement Health and Lifestyle questionnaire' if:
. Your po|cy has lapsed, or
. You are restartinq payments withrn six monthsand havea waiver ol prernium benef t 1or over USD 60,000 yearly, or
. You ar-" restarting payments aftet six months and have .:r waiver of prentium benef t.
We reserve the riqht to request addltionai medical and finan.ial requirements after reviewinq your policy (rncludinq amount of cover and
duratlon for whicl'r the plan has been lapsed/unpaid).

9 Privacy notice
The personal information requested in this form is collected and used by Zuri.h lnternational Life Limited (the Company) as Data Controller in lne

'10
Declaration
l/We declare that the answers l/we have given, whether in my/our handwrltlng or not, are true and.omplete to the best o{ my/our
knowledge and belie{ and will{onr the basis o{ this fonn.
l/We agree to inform the Company in wflting of any change to the iniormatiof provided in this forflr. l/We al5o agree to nflrrn Lh-"
Company of ary.hange ol name, address, et(. that rylay o((ur dur ng the life of this policy.
l/We 0ive the n€cessary authority for yolr to cont.-rct the certifie(s) oJ mylour documcnts directly if it is necessary to seek clarilication
reqardinq any part of the certification.
l/We declare that the pollcy owner(s) i5lare not resident(s) of llre United States inclucling any United States {ederally controlled territorles-
l/We declare that any premiums that l/we pay to tho policy w li not contravone any applicable exchanqe control regLtlat ons or trade or
economic sanctions.
l/We declare thal any premium paid to the Company is not of criminal origin or d re(tly or lndirectly /elated to criminal activities or any
a(tual or atlempted money launder ng or tax evaslon.
l/We request to restan the regular payments on my policv and/or the change in regular prenriums be applied to my/our olqtnal policy ln
accord.rnce wth Zurich lnternational Life Limited's stand.rld telms and conditlons. Fullterms and conditions are avaiiable on www.zurich..re.
l/We (onfirm thal l/we understand ihal changing the regular prernium is solely my/our own choice, and/or that of rny/our adviier and that
the acceptance of the asset link by Zurich lnternationai Life Lirnlted does not (onstitute a warranty or representation o1 the suitabllity of
the asset for investment purposes.

Contad details
l/We understand that for security purposes, the Company will regard the contact details provided as my/our autl]orised contact details and
that it is import.int that l/we Iet the Company know if any of these details change.
l/We con{irm that thjs/these sign"rture(s) is/are mine/ours or that/those of mylour appointed legal represeotative(s).
lf your signature is different from the signature in your passport/lD, or does not exist on the paisport/tD, or if your signature has
changed over a period of time, you will need to complete a 'Certifying signature form' and include a €ertified (opy of the
signature page of the passport even if it is not signed.

Country where this form was signed KA

Policy owner/Authorised signatory 1 Policy owner/Authorised signatory 2
Siqnature

Finan(ial Professional De.laration

d@AEEEE *. nn fln IIII
I declare that, to lhe be5t of my knowledge and belief, the inforrration given is true and shall Jorm the basis of the restart of polcy paymentr
any addrtional prefliums with Zurich lnternational Life Limited.
"rnd

lull name

5ignature

Date
nE En []EUu
Zurich lnternational Life Limlted ls registered ln Bahra n !nder Commer<ial Reqistration No. 17444 and is licensed as an Overseas lnsurance Firm -
Llfe lnsurance by the Centlal Bank of Bahrain. Zurich International Life Limiled is authorised by the Qatar Finan.ial Centre Regu atory Authorlty. zuf .h
lnternational Life Limited ls registered (Registration No. 63) under UAE Federal Law Number 6 of 2OOZ and ts activities ln the UAE are governed by such

business name of Zuri(h lntenlational Lile Limited (a (ompany incorporated in the lsle ol Man with liinilcd llability) whlch provides lile assurance, investnent

Llfe Limiied which provldes lfe assurance, investment and protection prodLrcts and is authorised by the lsle of Alan Finalrcial servlces Authority. Registered
ifl the lsle of Man nurnber 20126C. Registered officerZurich House, lsle of llan Business Park, Douglas, lsle ol Man, lM2 2QZ, British lsle!. l'elephone
+4416)4 662266'lelelax +44 1624 6620:8 wwwzurlchinternational.com Zrri(h lnternational Life Limited a<ting thr rgh i1s Singapore branch at
Singapore l-and Tower *29-01, 50 Raffles Place, Singapore 048623. Teephone+65 6876 6750 Telefax +65 6876 6751. Registered in Slngapore No. T05FC6754F.

l\.,1s P 13874 (72191s003)(07/20) CMs

 Zurich lnternational Life

o
ZURICH

Method of payment form

Completing this form

PIease use blue or black ink and write clearly in CApITAL letters. Please complete the forrn in Engllsh. The (ompleted torm should hot be
submitted direct to your bank.
Please take the time to read through these notes before completing this Jorm, as we wrll have to return this fol,n to you if any inform.-rtion
rsincorrect.or missinq. Please.omplete the personal deta ls sectlon and the scction appropriate to your intonclecl meihorj of
faymcnt.rnd
return the form to your televant financial professional or Zurich lnternalional Li{e.

Contact details
We adhere to 5trlct conf dentiality procedures when we .onrmunicate h/ith our cli-"nts. For security purposes, w,. will regard the details
you provide as your author sed contact details; it is therefore irnportaft that they are accurate and that you let us know f any oi these
details (hange.

Data protedion statement

The personal inforrnation (including heallh inforrratlof) that i5 supplied may be held and used by Zuri(h tnterrrational Life Lirnrtecl
(the Company) in the foilowinq ways:

. to pro(ess, evaluate and administer the contr.rcts/policies/claims

. to prevent and detect iraud and financlal (rimc
. to perform accounttng, statisti(al and research adivities.
ln order to carry out the above the Company may need to pass the information toi

' any Zurich lnsurance Group conrpanles, re-insurers, reference agencies, thitd parties who provide relevant serviaes to the Company .-rnd
relevant financlal profess onals

' countries outside the lsie of Man that maynot have equivalent levels of dota protection; however the Cornpany would be responsibie for
ensuring that equivale l levels of protectiorr are maintained
. publi. bodies lnclLlding the police, or insurers' database

' any relevant t.-rx authority or government.rl, regulatory or otl'rer bodies as requ red by law, regulai on, codes or guideiines and/or plrrsuant
to any order of a court of competent jurisdiction and the information may be transm tted by any usual means i;cluding the internet.
Where more than one form of (ontact details have been provided, the rnost appropriate method o{ communicatlon wlll be i.rsecl depencling
on the urqency aod 5ensitivity of the rnfofination.
Telephone calls may be recorded oI monitored in order to offer additional se.ur ty, resolve complaint5 and for trainifq, adrninistrative anc]
,t,rrl'ty DrJ,po\.,.
lndividuals are entitled to reccive (from the Company's Data Prote(tlon officer) a copy ol tlleir pcrsonal data helcJ by the company
(and r.ay be .harged the statlitory fee for thls) and to have any errors corrected.
1 Polir:y owner delaiis

Type ol pol, -"/" opllL,r I 01 8453972

P{rlicy/Application number (if known)

Policy owner llAPPlicant 1

r,tt"l lv, []r',r,, l=lvo, [v, [or. [other(p/easesrv*""t''l' [ -']

Famllyname HALPANDENIHEWA

FOIENAT(lC(S) SUDARSHISENANI

of any previous names or aliases used (includlng maiden

name)
Please give deiails

Policy owner 2/Applicant2 (wherc applicable)

rnt"|_-]r',l,[v,,[-lui,,[r,r,f]o,[other(P/ease9lve*o,m
tamily nanre

torename(s)

of any previous nanles or allases used (includl''g maiden

name)
Please give cletails
Credit card p::yrnenl
Assuran(e, sav ngsPlus arld vista
5u table {or use with Global cholce, Futura, lnternational Decreasing Term Ass!rance, lnlerrlational Term
tce pavo, i> Ihp ooli(V owner'q/apo'rranl: spou\e wp w ll reu"i'e
prt.,"r. ti,"n o"tyo",,eo Oy oolicyowrer./afoi.antsanotl-e, spo.-rses. 11
bc a{ LcptFd onlv suil"l)l'
r-" ;i ;iil.i; il i"" pori. l, o*n"'. ns1,.rri ons'f 'om or
lof ,liiin her Ihi' d part rc' w rl tr
anr oi,. n"o p.oof ot 'r
'h"i'prvinq I ptease arrange payment usinq one of the
1i} ;;;;iil;;il;
^,,on ;.*'tur n.rr. rr in;binurton of r'eg,rtar and single contriburtons,
oiher rfethods.

Credit card payment instruction

n"vlioio""jl .i,rio" t acle by your credit .ard company for colle(tion of your contr butions wlll be mei by the payor'
payment, please use a different paymont method
Credit card5 can only be used Ior reqular payments. lf you wisl] to mako a lump slrm

We only accept Visa oI Mastercard. (not available tor ffA AED clenominatcd policies)

special instructions for collection

AuthoritatioIl
account, as detailed below with unspecified
i authorise zurich lnternational Li{e, until lurther notice n writing, to debit my creclit card
,l
),.o,.n lnia,'rattonalitfe pollcy as and when they {all due and in respect of ch'rrqes for collection of
amounts in respect of the premiurff to,
the p.qmrL.l5 by rqilt raro tl-dt Jre oas(^d orto rL DyZL'irn lrte'n"Lroral Lile

Details of cLtrrent rcte-s of charges are available on rcquest. P/ease nole that zuk:h
lntefiatianal Life is not liable tor itny k>sses ari:itq as t
result of attioh taken by the ca|tlholdet's cretlit car.l conipany

credit card type

f-l v,', I\,4astercard

We do not accept prepaid or exchange cledit catds.

Preterred colledion dater

EE
*Your regular payment will be collected on this date or the nearest available date

Name of (ard issuer - such aJ H58c FAB

curren.y of (ard AED

Credit card expiry date

uE Llbl
Credil card number

E]!]ETTEEEEEIIEEEEE
Name on card SUDARSHI SENANI

Cardholder's address - as held by crcdit card company

AL QASR HOTEL, HOUSEKEEPING DEPARTMENT, PO BOX 75157' OUBAI'
UAE

that ihis authority in favour of Zuri(h lnternational Life remain in for(e until su(h time a5 l(an(el it in writing,
I understand

o,," En rFl Et{Eti