Please complete this form in BLOCK CAPITALS throughout.
SECTION 1 POLICY DETAILS
This form should only be used for Quantum policies issued after 6 April 2010. For Quantum policies issued before 6 April 2010
please contact our customer services team for further information.
Are you notifying us of any changes to your personal/company/trustee details as part of this application?
If yes, please provide details in Section 6 – Your additional notes.
Policyholder 1 Policyholder 2 (if applicable)
Country of residence for
Tax Reference Number
Are you a Speciﬁed US Person?
place of birth
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. More information
on US FATCA can be found at: www.irs.gov/Businesses/Corporations/Foreign-Account-Tax-Compliance-Act-FATCA
If you choose Yes to being a Speciﬁed US Person, you will need to provide us with your US Taxpayer Identiﬁcation Number (TIN)
or US Social Security Number (SSN).
If you choose 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 for the country in which you have obtained new citizenship.
If the policyholder is a corporate trustee, please complete Section 3.
If the policyholder is a trust or company, please complete Section 4.