Fillable DANSK BEGRING OM UDBETALING Danish business withdrawal request (RL360)

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DANSK BEGRING OM UDBETALING Danish business withdrawal request (RL360)

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1
Hvem er denne formular beregnet for?
Who is this form for?
Denne formular er beregnet for indehavere af danske policer, som ønsker en udbetaling fra deres police eller tilbagekøb af
policen i dens helhed eller enkelte dele af den.
This form is for policyholders of Danish policies who wish to take a withdrawal or surrender their policy in full or surrender a
policy segment(s).
Udfyldelse af denne formular
Completing this form
Ved at udfylde denne formular anmoder du om udbetaling af penge eller tilbagekøb af alle eller nogle dele af din police. Vi
anbefaler, at du taler med din uafhængige finansrådgiver, før du gør dette, så du er opmærksom på eventuelle skattebetalinger
i denne forbindelse. I tilfælde af tilbagekøb kan der forekomme gebyrer for ophævelse af policen før tid. Hvis du har brug for
hjælp til at udfylde formularen, kan du kontakte vores kundeservice på telefon +44 (0)1624 681 682 eller sende en e-mail til
csc@rl360.com.
By completing this form you will be withdrawing money or surrendering all or a number of segments from your policy. We
recommend that you speak to your Independent Financial Adviser before doing this, so that they can make you aware of any tax
charges that may apply. If surrendering there may be early surrender fees incurred. If you need help completing this form please
contact our Customer Services Team on +44 (0)1624 681682 or alternatively you can email csc@rl360.com.
Når du har udfyldt denne formular
When you have completed this form
Send venligst den originale formular med post eller kurer til: 3rd Party Team, RL360, International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, De Britiske Øer.
Please send the original form by post or courier to: 3rd Party Team, RL360, International House, Cooil Road, Douglas, Isle of Man,
IM2 2SP, British Isles.
Policenummer
Policy number
Forsikringstager(e)
Policyholder(s)
Aktuel bopæl
Current residential address
Telefon i dagtimerne
Daytime telephone
E-mail-adresse
Email address
DANSK BEGÆRING
OM UDBETALING
SERVICING
Danish business withdrawal request
2
Type af udbetaling (vælg venligst kun én) | Type of withdrawal (please select only one)
Udbetaling af et beløb. Venligst fortæl os beløbet.
Withdraw a fixed amount. Please tell us the amount.
Tages fra en bestemt konto (hvis relevant)
Venligst oplys hvilken konto.
To be taken from a specific fund (if applicable).
Please tell us which fund.
eller
Or
Policen tilbagekøbes i sin helhed*
Surrender Policy in full*
eller
Or
Enkelte dele af policen tilbagekøbes Fortæl os venligst, hvor mange dele, der skal tilbagekøbes
Surrender individual Policy segments Please tell us how many to segments to surrender
Betailings - instruktion
Payment details
Hvis du beder os om at udbetale et udtræk til en bankkonto, som vi ikke tidligere har foretaget udbetalinger til, bedes du give os
en kopi af din seneste kontoopgørelse, så denne konto kan omfatte transaktioner.
If you are asking us to pay a withdrawal into a bank account that we have not previously made payments to, please provide us
with a copy of your latest bank statement for this account to include transactions.
Kontohaver(e)
Account holder(s)
Kontonummer eller IBAN
Account number or IBAN
Bankens navn
Bank name
Bankens adresse
Bank address
Bankens SWIFT-/BIC-kode
Bank SWIFT code/BIC
Ved at underskrive nedenfor bekræfter du, at du har læst de vigtige bemærkninger, der er anført på side 3 i denne formular.
By signing below you are confirming that you have read the important notes on page 3.
Underskrift 1 Underskrift 2 (hvis relevant)
Signature 1 Signature 2 (If applicable)
For- og efternavn(e)
Full name
Dato
Date
Fødselsland
Country of birth
Skattemæssigt/-e
hjemstedsland eller -lande
Country or countries of tax residence
Skatteregistreringsnummer
eller tilsvarende
Taxpayer Identification Number or functional equivalent.
”Tilsvarende” vil sige et andet nummer, der er udstedt til dig af dine lokale myndigheder. Eksempler: opholdstilladelsesnummer,
visumnummer, socialforsikringsnummer (Storbritannien)
A functional equivalent is another number that has been issued to you by your local authorities. Examples: resident card number,
visa number, UK national insurance number
3
Specificerede amerikanske personer
Specified US Persons
En specificeret amerikansk person vil sige en amerikansk statsborger eller en skatteborger, som har bopæl eller postadresse i
USA, eller som enten har et amerikansk pas, en amerikansk arbejdstilladelse (”Green Card”), eller som var født i USA og endnu
ikke har givet afkald på sit amerikanske statsborgerskab.
Specified US Person means a US citizen or tax resident individual who has a US residential/correspondence address or who either
holds a US Passport, a US Green Card or who was born in the US and has not yet renounced their US citizenship.
Yderligere oplysninger om US FATCA findes på: www.irs.gov/Businesses/Corporations/Foreign-Account-Tax-Compliance-Act-FATCA.
More information on US FATCA can be found at: www.irs.gov/Businesses/Corporations/Foreign-Account-Tax-Compliance-Act-FATCA.
Er du en specificeret Ja Nej
Ja Nej
amerikansk person?
Are you a Specified US Yes No Yes No
Person?
Hvis du har sagt Ja til at være en specificeret amerikansk person, bedes du angive dit amerikanske individuelle
skatteregistreringsnummer (Individual Taxpayers Identification Number – ITIN) eller socialsikringsnummer (Social Security
Number – SSN):
If you have ticked Yes to being a US Specified Person, please provide your US Individual Taxpayers Identification Number (ITIN)
or Social Security Number (SSN):
Hvis du har sat kryds ved Nej, men du har en amerikansk bopæl/postadresse, et amerikansk pas, en amerikansk arbejdstilladelse
(”Green Card”), eller hvis du er født i USA, skal du give os dokumentation på, at du arbejder på at give eller har givet afkald på
dit amerikanske statsborgerskab. RL360 kan acceptere en certificeret kopi af din DS-4083 formular (også kendt som CLN –
Certificate of Loss of Nationality) og/eller en certificeret kopi af dit pas fra det land, hvor du får ny indfødsret.
If you have ticked No but you have a US residential/correspondence address, hold a US Passport, a US Green Card or you were
born in the US, you will need to provide us with documentary evidence that you are in the process of or have renounced your US
Citizenship. RL360 can accept a certified copy of your DS-4083 form (also known as CLN – Certificate of Loss of Nationality) and/or
a certified copy of your passport in which you are obtaining new citizenship.
Vigtige bemærkninger | Important notes
Udbetalinger
Withdrawals
Jeg bemyndiger hermed RL360 Insurance Company Limited til at udbetale et beløb fra min police i overensstemmelse med
oplysningerne på side to i denne formular. Jeg er klar over, at alle udbetalinger sker i henhold til forsikringsvilkårene for
min police, og at RL360 Insurance Company Limited (selskabet) udbetaler det ønskede beløb i overensstemmelse med de
instrukser, der er givet i denne formular.
I hereby request and authorise RL360 Insurance Company Limited to pay a withdrawal(s) from my policy in accordance with the
details on page two of this form. I understand that any withdrawal(s) will be subject to my Policy Terms and Conditions and that
RL360 Insurance Company Limited (the Company) pay the withdrawal amount in-line with the instructions provided on this form.
Fuldt tilbagekøb eller tilbagekøb af enkelte dele
Full surrenders or surrender of segments
Jeg anmoder om, at policen med det ovenfor anførte nummer tilbagekøbes i overensstemmelse med policens vilkår, og at
RL360 Insurance Company Limited (selskabet) betaler tilbagekøbsværdien i overensstemmelse med de instrukser, der er givet
i denne formular. Jeg bekræfter, at denne udbetaling vil frigøre selskabet fra alle forpligtelser og krav i henhold til policen eller
de tilbagekøbte dele af denne.
I request that the above numbered Policy be surrendered in accordance with the Terms and Conditions of the Policy and that RL360
Insurance Company Limited (the Company) pay the surrender value in-line with the instructions provided on this form. I confirm that
this payment will discharge the Company from all liabilities and claims arising out of the Policy or surrendered Policy segments.
Jeg bekræfter, at jeg er berettiget til afkastet af policen med det ovenfor anførte nummer, og at der ikke er afsagt
konkursdekret over mig. Jeg er ikke under konkurs, og policen er ikke blevet overdraget eller afhændet, ligesom ingen anden
har rettigheder i policens tilbagekøbsværdi (bortset fra de oplysninger, der findes i eventuel vedlagt dokumentation).
I confirm that I am entitled to the proceeds of the above numbered Policy and that no receiving order has been made against
me. I am not bankrupt and the Policy has not been assigned or transferred, nor does any other person have legal rights to the
surrender proceeds under the Policy (other than the details provided in any supporting documentation).
Privatlivspolitik | Privacy Policy
Vores fulde privatlivspolitik kan ses på www.rl360.com/privacy eller kan rekvireres ved at anmode om en kopi fra vores
databeskyttelsesrådgiver.
Our full privacy policy can be viewed at www.rl360.com/privacy or can be obtained by requesting a copy from our Data
Protection Ocer.
RL059d 02/21
RL360 Insurance Company Limited. Registered Oce: International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, British Isles. Registered in the Isle of Man number 053002C. RL360
Insurance Company Limited is authorised by the Isle of Man Financial Services Authority.
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DANSK BEGRING OM UDBETALING Danish business withdrawal request (RL360)

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