Acuerdo de Subscripción

Transcripción

FORM IN102-2
ver s i on 05/2015
w w w. i n v e s t o r s - t r u s t . c o m
SUBSCRIPTION AGREEMENT
ACUERDO DE SUBSCRIPCIÓN
May / Mayo 2015
You should view your unit linked policy as a long-term investment. Early surrender/withdrawal of funds from your policy will result in penalty charges and the
possibility of your original investment goals not being satisfied. Prior to purchasing this product please ensure that you fully understand all of the terms of the policy
including the charges and possible penalties that could apply in the event of early surrender/withdrawal. This is a long-term commitment so make sure you understand how
this policy satisfies your investment goals and why it is suitable for you, before you decide to purchase – the choice is yours.
All Policies are issued by the Investors Trust Segregated Portfolio of Investors Trust Assurance SPC, a Cayman Islands segregated portfolio company.
Usted debe ver su póliza como una inversión a largo plazo. Un rescate/retiro anticipado de fondos de su póliza resultará en cargos de penalidad y la posibilidad de no cumplir sus metas
de inversión satisfactoriamente. Antes de adquirir este producto, asegúrese de entender completamente todos los términos de la póliza, incluyendo los cargos y posibles penalidades
que puedan ser aplicados en el evento de un rescate/retiro anticipado. Este es un compromiso a largo plazo, por lo tanto es muy importante que entienda cómo esta póliza responde
a sus objetivos de inversión y por qué es conveniente para usted, antes de decidir su compra - la elección es de usted.
Todas las pólizas son emitidas a través de Investors Trust Segregated Portfolio de Investors Trust Assurance SPC, una compañía de portafolio segregado de las Islas Caimán.
FILLING IN THIS FORM / Como completar este Acuerdo de Subscripción
This document is intended to be made available only in jurisdictions in which this insurance product is permitted to be offered or sold to and shall not be construed as an offer to sell or a
solicitation to buy or a provision of insurance in any other jurisdiction. The company does not offer or sell any insurance product in a jurisdiction in which such offering or sale of an insurance
product is not permitted under the laws of such jurisdictions.
This Subscription Agreement should be supplied in conjunction with the applicable product brochure. If you are in doubt or unsure as to the contents or implications of this agreement, you
should obtain independent legal advice.
Please complete in block letters and countersign any changes made.
Please complete all required information. Failure to provide all relevant information may result in a delay in the processing of your Subscription Agreement.
Este documento está destinado a ser puesto a disposición sólo en las jurisdicciones en que se permita la oferta o la venta de este producto de seguro, por lo tanto, no debe ser interpretado como una oferta
de venta, una solicitud de compra, o una disposición de producto de seguro en cualquier otra jurisdicción. La empresa no ofrece ni comercializa los productos de seguros en una jurisdicción en la que dicha
oferta o venta no esté permitida bajo las leyes de dicha jurisdicción.
Este Acuerdo de Subscripción debe ser suministrado conjuntamente con el folleto del producto aplicable. Si tiene alguna duda o no está seguro sobre el contenido o las implicaciones de este acuerdo, usted
debe obtener asesoramiento jurídico independiente.
Por favor, complete dicho acuerdo con letra clara y corrobore cualquier cambio realizado.
Por favor, complete toda la información requerida. Si no se proporciona toda la información pertinente puede resultar en un retraso en la tramitación de su Acuerdo de Subscripción.
Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated “Secure” by A.M. Best Company. For the latest rating, access www.ambest.com. Investors Trust
Assurance SPC is a member of the Association of International Life Offices (AILO). The contents are not to be reproduced or distributed to the public or press. Please consult your own
legal, tax or investment professional before making any financial decisions.
Investors Trust es una marca registrada de Investors Trust Assurance SPC, calificada “Segura” por A.M. Best Company. Para obtener la calificación más actualizada, visite www.ambest.com. Investors
Trust Assurance SPC es miembro de la Association of International Life Offices (AILO). Este documento no puede ser reproducido o distribuido al público o prensa. Antes de tomar cualquier decisión
financiera, consulte con un asesor profesional para obtener información sobre regulaciones legales, impuestos y/o planificación financiera.
Financial Strength Rating
A
M
BEST
B++ Good
‡ Third party trademarks are used with the permission of their owners.
‡ Las marcas registradas de terceros son utilizadas con el permiso de sus dueños.
Publication Date: May 2015 / Fecha de Publicación: Mayo de 2015
FORM IN102-2
ver s i on 05/2015
SUBSCRIPTION AGREEMENT BETWEEN / Acuerdo de Subscripción entre:
1. ITA BANK AND TRUST COMPANY LTD. of Suite 4210, 2nd Floor Canella Court, 48 Market Street, Camana Bay,
PO Box 32203, Grand Cayman KY1-1208, Cayman Islands as trustee of the Investors Trust Cayman
(respectively the “Trustee” and the “Trust”) and
2. Each of the Plan Participants (as hereinafter defined).
A.
S U B S C R IP T IO N A G R E E ME NT
ACUERDO DE SUBSCRIPCIÓN
PLAN PARTICIPANT / Participante del Plan
(the “First Plan Participant”); and / (el “Primer Participante del Plan”); y
LAST NAME or CORPORATE NAME (For corporate and other legal entities only) / Apellidos ó Nombre de la Corporación
FORENAME(S) / Nombre(s)
RESIDENTIAL ADDRESS / Dirección Residencial
CITY / Ciudad
STATE/PROVINCE / Estado/Provincia
ZIP CODE / Código Postal
COUNTRY / País
NATIONALITY / Nacionalidad
PASSPORT/ID # / Número de Pasaporte/DNI
PASSPORT/ID DATE OF ISSUE / Fecha de Emisión Pasaporte
PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración Pasaporte
DATE OF BIRTH / Fecha de Nacimiento
GENDER / GÉNERO
DD / MM / AAAA
MALE / MASCULINO
DD / MM / AAAA
DD / MM / AAAA
FEMALE / FEMENINO
RESIDENCE TELEPHONE / Teléfono Residencial
AREA CODE / Código de Área
COUNTRY CODE / Código de País
PHONE NUMBER / Teléfono
MOBILE TELEPHONE / Teléfono Celular
FAX TELEPHONE / Teléfono Fax
BUSINESS TELEPHONE / Teléfono Comercial
OCCUPATION / Ocupación
E-MAIL / Correo Electrónico
BUSINESS ADDRESS / Dirección de Negocios
CITY / Ciudad
B.
COUNTRY / País
JOINT PLAN PARTICIPANT / Co-Participante del Plan
(the “Joint Plan Participant”) (the First Plan Participant and the Joint Plan Participant, together, the “Plan Participants”). / (el “Co-Participante del Plan”) (el Primer Participante del Plan y el
Co-Participante del Plan, en conjunto como los “Participantes del Plan”)
LAST NAME or CORPORATE NAME (For corporate and other legal entities only) / Apellidos ó Nombre de la Corporación
RESIDENTIAL ADDRESS / Dirección Residencial
CITY / Ciudad
COUNTRY / País
NATIONALITY / Nacionalidad
PASSPORT/ID # / Número de Pasaporte/DNI
PASSPORT/ID DATE OF ISSUE / Fecha de Emisión Pasaporte
PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración Pasaporte
GENDER / GÉNERO
DD / MM / AAAA
MALE / MASCULINO
DD / MM / AAAA
DD / MM / AAAA
FEMALE / FEMENINO
RESIDENCE TELEPHONE / Teléfono Residencial
MOBILE TELEPHONE / Teléfono Celular
OCCUPATION / Ocupación
E-MAIL / Correo Electrónico
BUSINESS ADDRESS / Dirección de Negocios
CITY / Ciudad
COUNTRY / País
If Plan Participant(s) is/are a Corporation, please complete form IP142-1 Add/Remove Authorized Person.
En caso que el/los Participante(s) del Plan fuese/fueran una Corporación, se debe completar el formulario IP142-2 Agregar/Remover Persona Autorizada.
Plan Participant Initials
Iniciales del Participante del Plan
–1–
Joint Plan Participant Initials
Iniciales del Co-Participante del Plan
C.
NOMINATION OF BENEFICIARIES / Designación de Beneficiarios
The Plan Participants hereby designate the following as Primary and Contingent Beneficiaries: / El/Los Participante(s) del Plan por la presente designa(n) a los siguientes beneficiarios primarios y contingentes:
PRIMARY BENEFICIARY / Beneficiario Principal
RELATIONSHIP TO PLAN PARTICIPANT / Relación con el Participante
LAST NAME / Apellido
PASSPORT/ID # / Nro. de Pasaporte/DNI
DD / MM / AAAA
Spouse / Conyugue
Child / Hijo(a)
PASSPORT/ID DATE OF ISSUE / Fecha de Emisión
DD / MM / AAAA
DD / MM / AAAA
PERCENTAGE / Porcentaje
DD / MM / AAAA
%
Other / Otro: _________________
PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración
Spouse / Conyugue
Child / Hijo(a)
Other / Otro: _________________
DD / MM / AAAA
DD / MM / AAAA
%
CONTINGENT BENEFICIARY / Beneficiario Contingente
DD / MM / AAAA
Spouse / Conyugue
Child / Hijo(a)
DD / MM / AAAA
DD / MM / AAAA
Other / Otro: _________________
DD / MM / AAAA
%
D.
Spouse / Conyugue
Child / Hijo(a)
Other / Otro: _________________
DD / MM / AAAA
DD / MM / AAAA
%
INVESTMENT DETAILS / Detalles de Inversión
The Plan Participants shall make the following investments: / El/Los Participante(s) del Plan tendrán que realizar las siguientes inversiones:
PLAN CURRENCY
Divisa del Plan
EUR €
USD $
REGULAR ANNUAL CONTRIBUTION AMOUNT 1
Monto Anual de Contribución Regular 1
,
PRODUCT TYPE
Tipo de Producto
.
PRODUCT TYPE
Tipo de Producto
LUMP SUM INVESTMENT AMOUNT 2
Monto de Contribución Única 2
,
.
GBP £
EVO 10yr/años
EVO 20yr/años
S&P500 15yr/años 3
EVO 5yr/años
EVO 15yr/años
EVO 25yr/años
S&P500 7 yr/años 3
Platinum Select
Platinum
Platinum Plus
Access Portfolio 5000 Series
Access Portfolio 8000 Series
Product code / Código del Producto
Product code / Código del Producto
Fixed Income 15yr - Variable Rate 3
Renta Fija 15 años - Tasa Variable 3
Fixed Income 3yr - Fixed Rate 3
Renta Fija 3 años - Tasa Fija 3
Fixed Income 5yr - Fixed Rate 3
Renta Fija 5 años - Tasa Fija 3
Access Portfolio Plus
Flex Plan 4
1. Minimum Contribution USD/EUR/GBP 1,200 annually (EVO 5 yr USD/EUR/GBP 2,400 annually ; S&P500 15yr and Fixed Income 15yr: USD 2,400 annually) / Contribución Mínima de USD/EUR/GBP 1.200 anual (EVO 5 años USD/EUR/GBP 2.400 anual; S&P 500 15 años y Renta Fija 15 años: USD 2.400
anual) 2. Minimum Contribution per product: S&P500 7 yr, Fixed Income 3yr and Fixed Income 5 yr - USD 10,000; Platinum - USD/EUR/GBP 10,000; Platinum Select USD/EUR/GBP 50,000; Platinum Plus USD/EUR/GBP 100,000; Access Portfolio products USD/EUR 75,000 (GBP 50,000); Flex Plan USD/
EUR/GBP 100. / Contribución Mínima por producto: S&P500 7 años, Fixed Income 3 años y Fixed Income 5 años- USD 10.000; Platinum - USD/EUR/GBP 10.000; Platinum Select USD/EUR/GBP 50.000; Platinum Plus USD/EUR/GBP 100.000; Productos de Access Portfolio USD/EUR 75.000 (GBP 50.000);
Plan Flex USD/EUR/GBP 100. 3. USD Only / USD únicamente. 4. This product is only available for existing Plan Participants with inforce or paid up policies, or Introducers. / Este producto está disponible únicamente para clientes existentes con pólizas pagadas o vigentes, e Introductores activos.
E.
THE PLAN PARTICIPANTS’ CHOICE OF INVESTMENT FUND(S) AND THE INVESTMENT IN EACH ARE SPECIFIED BELOW.5 /
Por favor indicar los Fondos seleccionados y sus Porcentajes Respectivos de Inversión.5
FUND CODE
CÓDIGO DEL FONDO
FUND NAME
Min. $/€/£ 120 per fund
NOMBRE DEL FONDO
Min. $/€/£ 120 por fondo
%
%
%
%
%
%
%
%
%
%
5. a. For all Evolution and Platinum products, if no investment fund is specified or if any of the specified funds are unavailable, the Company will allocate the contributions into a cash equivalent fund. b. For all S&P 500 products, the Company will allocate the contributions to a structured
note product with relative returns linked to the performance of index S&P 500. No choice of investment fund(s) is necessary. c. For all Fixed Income products, the Company will allocate the contributions to a USD fund portfolio with fixed competitive interest rate. No choice of investment
fund(s) is necessary. d. For all Access Portfolio products, contributions will be allocated into cash. No choice of investment fund(s) is necessary. e. For all Flex Plan products, contributions will be allocated into a cash equivalent fund. No choice of investment fund(s) is necessary. / 5. a.
Para todos los productos Evolution y Platinum, si no se especifica ningún fondo de inversión o si alguno de los fondos especificados no están disponibles, la Compañía le asignará las contribuciones a un fondo equivalente a efectivo. b. Para todas los productos S&P 500, la Compañía
destinará las contribuciones a notas estructuradas con retornos relativos vinculados al rendimiento del índice S&P 500. c. Para todos los productos de Renta Fija, la Compañía destinará las contribuciones a una cartera de fondos en USD con tasa fija de interés competitiva. d. Para
todos los productos Access Portfolio, las contribuciones se asignarán a dinero en efectivo. e. Para todos los productos Flex, las contribuciones se destinarán a un fondo equivalente a efectivo.
–2–
F.
CONTRIBUTION METHOD AND INSTRUCTIONS /
Métodos e Instrucciones de Pago
CREDIT CARD / TARJETA DE CRÉDITO
Major Credit Cards are accepted. Se aceptan las principales tarjetas de crédito.
International Wire Transfers are accepted. Se aceptan transferencias bancarias internacionales.
WIRE TRANSFER / TRANSFERENCIA BANCARIA
CHECK / CHEQUE
DIRECT DEBIT / DÉBITO DIRECTO
Only checks drawn from US registered Bank Accounts are accepted. Please make
check payable to Investors Trust. Se aceptan cheques pagaderos sobre cuentas de bancos
Direct debit from US bank accounts are limited to amounts below USD 100,000.
Se aceptan débitos directos de cuentas de bancos de EE.UU. por cantidades menores a USD 100.000.
de EE.UU. Los cheques deben ser pagaderos a Investors Trust.
To provide the instructions of your selected contribution method please complete and attach the Payment Authorization Form (IP114-1).
Para proveer instrucciones completas de su método de pago seleccionado por favor adjunte el formulario de Autorización de Pago (IP114-2).
G.
ADDITIONAL INFORMATION /
Información Adicional
Are any of the Plan Participants and/or Payors, currently or have been in the past, one of the following / Por favor indique si alguno de los Participantes del Plan y/o Pagadores se identifica en la
actualidad o en el pasado con algunas de las siguientes opciones:
A senior military, governmental, or political official in a non-US country? If yes, please complete form IG132-2 Source of Funds Questionnaire
Un militar de alto rango, funcionario gubernamental o político de un país distinto a los EE.UU.? Si es así, por favor complete el formulario IG132-2 Cuestionario de Procedencia de los Fondos
Closely associated with or an immediate family member of such official? If yes, please complete form IG132-2 Source of Funds Questionnaire
Un pariente cercano o una persona estrechamente asociada con un funcionario con las características descritas en la opción anterior? Si es así, por favor complete el formulario IG132-2 Cuestionario de Procedencia
de los Fondos
None of the above
Ninguna de las opciones anteriores
H.
PREFERRED LANGUAGE FOR COMMUNICATIONS /
Idioma de preferencia para comunicaciones
ENGLISH
INGLÉS
I.
SPANISH
PORTUGUESE
ESPAÑOL
PORTUGUÉS
CHINESE TRADITIONAL
CHINO TRADICIONAL
CHINO SIMPLIFICADO
JAPANESE
JAPONÉS
RUSSIAN
RUSO
MAILING ADDRESS / Dirección para Correspondencia
This address will be used if the Company needs to physically mail the Plan Participant(s) any Plan related documents. / Esta dirección se utilizará si la Compañía necesitara enviar al/los Participante(s)
del Plan documentos físicos relacionados al Plan de Inversión. (select only one option / seleccione una opción únicamente)
FIRST PLAN PARTICIANT - Residential Address
FIRST PLAN PARTICIANT - Business Address
JOINT PLAN PARTICIPANT - Residential Address
JOINT PLAN PARTICIPANT - Business Address
PRIMER PARTICIPANTE DEL PLAN - Dirección Residencial
PRIMER PARTICIPANTE DEL PLAN - Dirección de Negocios
CO-PARTICIPANTE DEL PLAN - Dirección Residencial
J.
CHINESE SIMPLIFIED
CO-PARTICIPANTE DEL PLAN - Dirección de Negocios
ISSUED POLICY TYPE / DELIVERY METHOD Tipo de Póliza a Emitir / Método de Entrega
(select only one option / seleccione una opción únicamente)
E-POLICY
PÓLIZA ELECTRÓNICA
Commitment
to Green
Select electronic delivery of the policy documents and receive a USD/EUR 25 (GBP 15) rebate as a reward for supporting our Green initiative!
¡Opte por recibir los documentos de la póliza electrónicamente y reciba una bonificación de USD/EUR 25 (GBP 15) como recompensa por apoyar nuestra iniciativa ecológica!
6
PRINTED POLICY DELIVERED TO MY INTRODUCER
6
PÓLIZA IMPRESA PARA SER ENVIADA A MI INTRODUCTOR
PRINTED POLICY DELIVERED TO THE SELECTED MAILING ADDRESS 6
PÓLIZA IMPRESA PARA SER ENVIADA A LA DIRECCIÓN PARA CORRESPONDENCIA SELECCIONADA.
6
6. Delivery of printed policies is not available in all countries, verify with the Company before submitting the Subscription Agreement. If the selected delivery method is not available in your country, the Company will send an electronic policy (e-Policy) instead.
La entrega de las pólizas impresas no se encuentra disponible en todos los países, verifique con la Compañía antes de presentar el Acuerdo de Suscripción. Si el método de entrega seleccionado no está disponible en su país, la Compañía enviará una póliza electrónica (e-Policy).
K.
EXISTING POLICIES / Pólizas Existentes
Please provide details of any existing Investors Trust’s policies you have or are making payments to (if applicable) / Por favor, proporcione los detalles de todas las pólizas de Investors Trust que usted tenga o en las
cuales realice pagos (si aplica)
PRODUCT TYPE
Tipo de Producto
POLICY NUMBER
Número de Póliza
PRODUCT TYPE
Tipo de Producto
POLICY NUMBER
Número de Póliza
–3–
L.
DECLARATION /
Declaración
by the Plan Participants to the Trustee:
NOW IT IS HEREBY AGREED AS FOLLOWS
Each Plan Participant jointly and severally:
1.DEFINITIONS
(1)represents that the information provided by the Plan Participants in this Subscription
Agreement is accurate and complete;
In addition to terms otherwise defined herein, where the context so admits the following
expression shall have the following respective meanings:
(2)acknowledges that a copy of the Declaration of Trust relating to the Investors Trust Cayman dated
November 21, 2011 (the “Declaration of Trust”) has been provided to them;
“Beneficiaries” means the Primary Beneficiaries and Contingent Beneficiaries designated in
the Nomination of Beneficiaries Section of this Subscription Agreement as beneficiaries and
as applicable the estate of the Insured designated in Section 6 of this Subscription Agreement
as beneficiary.
(3)desires and hereby requests the Trustee to constitute a Sub-fund for the benefit of the
Beneficiaries;
(4)directs the Trustee to invest funds contributed by the Plan Participants in a Policy issued by
the Insurance Company allocated to such Sub-fund;
(5) represents and acknowledges that each Plan Participant has read carefully this
Subscription Agreement, the Declaration of Trust and the form of Policy to be entered into
between the Trustee and the Insurance Company;
(6) represents, acknowledges, and agrees that the Plan Participants have full responsibility for
the selection and choice of Investment Plans;
(7) represents and acknowledges that each of them has seen and signed the Plan Illustration
or any substitute document as established by the Company, attached to this Subscription
Agreement;
“Code” means the Internal Revenue Code of 1986.
“Insurance Company” means Investors Trust Assurance SPC on behalf of Investors Trust
Segregated Portfolio, or another insurance company (or segregated portfolio thereof)
selected.
“Insured” means the Plan Participant(s) (unless otherwise specified in this Subscription Agreement)
as the person(s) whose life is insured under each Policy.
“Investment Plans” means the investment funds, specified by the Plan Participants in or
pursuant to this Subscription Agreement, in which the Trustee shall direct the Insurance
Company to invest funds contributed by the Plan Participants.
“Plan” means the arrangement whereby the Trustee makes payments related to one or more
Policies for the benefit of one or more of the Beneficiaries with monies received from the Plan
Participants.
(8)represents and warrants that it is not:
a. a citizen or resident of the United States of America;
“Policies” means insurance policies, supplemental to a master insurance policy, which
insures the life of the Insured that are purchased from the Insurance Company in accordance
with the terms of the Plan.
b. or a corporation or other entity deemed situated in the United States of America under
the tax laws and Regulations (as defined in the Declaration of Trust) of the United
States of America; or
“Time of Maturity” means the date on which the Policies mature.
c.physically present in the United States of America for a number of days in a taxable
year which would result in it being taxable as a resident alien under the “substantial
presence” test of Section 7701(b) of the Code; or
“Trust” means the trust declared by the Trustee for the Plan, currently known as the Investors
Trust Cayman.
d. a member of the public In the Cayman Islands. Each Plan Participant hereby represents,
warrants, and agrees that:
“Trustee” means the trustee or trustees holding office under the Trust from time to time.
OTHER INTERPRETATION
i. it is aware that any failure to comply with the foregoing may result in material adverse
tax consequences and that the Trustee shall have no liability therefor; and
(a) the singular shall include the plural and vice versa;
ii. it will immediately advise the Trustee should there be any failure to comply with the
foregoing;
(b) the masculine gender shall include the feminine gender and vice versa;
(c) the neuter gender shall include the masculine and feminine and vice versa;
(9)represents, acknowledges and agrees that the Plan Participants have not and will not
contribute to the Trust any criminal property (as that term is defined in the Proceeds of
Crime Law, 2008 of the Cayman Islands);
(d) persons shall include companies, corporations, organizations, partnerships and other
legal entities;
(10) represents, acknowledges, and agrees that all funds must be sent directly to the Trustee
either by check, wire or credit card payment and that any funds given to any intermediary
will be at the sole risk of the Plan Participants.
(f) this Subscription Agreement shall be construed in tandem with the provisions of the Trust
Deed but to the extent that any provisions hereof are inconsistent therewith, the terms of
the Trust Deed shall prevail;
WHEREAS
(g) capitalized terms used but not otherwise defined in this Subscription Agreement have the
meanings assigned thereto in the Trust Deed.
(e) headings shall not be construed as part of this document;
The Trustee has established the Investors Trust Cayman trust under the Trusts Law (as revised) of
the Cayman Islands;
A separate sub-fund shall be constituted under the Trust herein (the “Sub-fund”);
Under the terms of the Trust, using one or more Sub-funds the Trustee shall purchase one or more
insurance policies from the Investors Trust Segregated Portfolio of Investors Trust Assurance SPC
(respectively the “Policies”, the “Segregated Portfolio” and the “Insurance Company”) with monies
received from Plan Participants (the “Plan”);
The Trustee shall direct the Insurance Company to invest the premium payments paid from the Sub-fund
in investment funds specified by the Plan Participants (the “Investment Plans”);
The Trustee shall administer the Plan in accordance with the terms of the Trust and this
Subscription Agreement and both the selection of the Investment Plans and the Beneficiaries
and the mode of distribution of their benefits shall be set as forth by the Plan Participants in this
Subscription Agreement.
2. FRAUDULENT DISPOSITIONS
Each Plan Participant warrants that no transfer of money or other property by them to the
Trustee will at the time made constitute a fraudulent disposition under applicable law, i.e.
that each such transfer has not been made at an undervalue and has not been made with an
intention to defraud a creditor of the Plan Participants.
3. THE TRUST INSTRUMENT
Each Plan Participant agrees that it shall be subject to and bound by all of the provisions of
the Declaration of Trust and this Subscription Agreement.
Without limiting the generality of the foregoing, each Plan Participant acknowledges and
agrees: that funds contributed by the Plan Participants will be credited to a Sub-fund and used
to purchase one or more Policies for the benefit of one or more of the Beneficiaries; that the
making of such contribution constitutes each Plan Participant’s agreement to the terms of the
Declaration of Trust and this Subscription Agreement and such Plan Participant’s agreement
to be bound thereby.
4. PURCHASE OF THE INVESTMENT PLANS
With funds received from the Plan Participants, the Trustee shall purchase one or more Policies
and shall continue to pay the premiums due thereon so long as funds contributed by the Plan
Participants are available in the Sub-fund.
–4–
L.
DECLARATION (continued) /
Declaración (continuación)
5. PAYMENTS TO THE TRUST
10.CONFIRMATION OF REPRESENTATIONS AND WARRANTIES / INDEMNITY
The Plan Participants have opted for a method of payment to the Trustee, as shown in this
Subscription Agreement, and such method may be changed by the Plan Participants, if
agreed to by the Trustee, after written notice requesting a change has been given by the Plan
Participants to the Trustee.
Each Plan Participant hereby confirms the accuracy of all information and the validity of all
representations and warranties provided to the Trustee in connection with the Plan and/or the
subscription for Investment Plans and for the Policy, howsoever provided, including the terms
of this Subscription Agreement and the contents of any personal or medical questionnaire
(together “Representations & Warranties”). Each Plan Participant acknowledges that certain
of such information will be provided to the Insurance Company on behalf of the Segregated
Portfolio as the issuer of the Policy and potentially to reinsurers thereof, and that any
inaccuracy therein may result in the invalidity of such Policy or the investments in the related
Investment Plans and the loss of all funds contributed or paid in relation thereto. Each Plan
Participant hereby undertakes to inform the Trustee of any change in any matter that forms the
subject of any of the Representations & Warranties.
6. THE BENEFICIARIES
The names of those who are to be Beneficiaries are (subject to the last sentence of this
Section) as listed in the above Nomination of Beneficiaries section of this Subscription
Agreement are subject to compliance with applicable law (including laws and regulations
directed at the prevention of money laundering) at any time, and from time to time. Upon
receipt by the Trustee of a written notice signed by all the Plan Participants, Beneficiaries
may be deleted or added or the order or proportion of their potential benefit may be
changed.
Each Plan Participant hereby undertakes to indemnify, defend, and hold harmless the Trustee
against any loss or damage (including, without limitation, attorney’s fees) occasioned by any
inaccuracy in any of the Representations & Warranties or failure to advise the Trustee of any
change in any matter that forms the subject of any of the Representation & Warranties.
If there are surviving Primary Beneficiaries at the time of a distribution from the Subfund, payment of such funds shall be made to the surviving Primary Beneficiaries in
proportion to the percentage entitlements of such Primary Beneficiaries as set out in
this Subscription Agreement (such that if there is only one surviving Primary Beneficiary
such surviving Primary Beneficiary shall receive all such funds). If there are no surviving
Primary Beneficiaries at the time of a distribution from the Sub-fund, payment of such
funds shall be made by the Trustee to each Contingent Beneficiary in proportion to the
percentage entitlements of such Contingent Beneficiary as set out in this Subscription
Agreement (such that if there is only one surviving Contingent Beneficiary such surviving
Contingent Beneficiary shall receive all such funds). If there are no surviving Primary
Beneficiaries or Contingent Beneficiaries at the time of the distribution of funds from the
Sub-fund, payment of such funds shall be made by the Trustee to the estate of the Insured.
Each Plan Participant agrees that the Trustee shall be entitled to rely on and to act in
accordance with any written instruction purported to be provided by a Plan Participant and
each Plan Participant hereby undertakes to indemnify, defend, and hold harmless the Trustee
against any loss or damage (including, without limitation, attorney’s fees) occasioned by the
Trustee acting in accordance with any such instruction.
11.PAYMENT OF BENEFITS
The Trustee shall ensure that payments are made to the Beneficiaries in respect of proceeds
received from the Insurance Company upon the death of the insured under a Policy, in
accordance with the Policy’s Death Benefit Provisions.
7. DEFAULT IN CONTRIBUTION PAYMENTS
12.FEES AND EXPENSES
If the Plan Participants fail to make the necessary scheduled contribution, the Trustee shall not
be under any obligation to make any payment on any Policy if funds are not available within
the Sub-fund for such purpose. Therefore in the absence of due Policy premium payments
within the Policy’s pre-established grace period and subject to the discretion of the Insurance
Company, the Policy may be lapsed and as permitted by applicable law funds (if any) may
be requested by the Plan Participants, in accordance with the Policy’s Surrender Provisions.
The Trustee, Administrator (if any exists) and Insurance Company shall charge its fees and
expenses as provided in the Trust Deed and Policy.
13.VERIFICATION OF IDENTIFICATION AND SOURCE OF FUNDS
As part of the Trust’s responsibility for the prevention of money laundering, and in regard
to other matters, the Trustee will require detailed verification of each Plan Participant and
Beneficiary’s identity and the source of the subscription funds.
8. INVESTMENT SELECTIONS
To the extent that any Policy enables a choice of investments for a Sub-fund, the Trustee
shall instruct that such investments be made in accordance with the directions of the Plan
Participants as set forth in this Subscription Agreement. Changes in investment selection may
be made at any time and from time to time by all the Plan Participants as permitted by the
Insurance Company, the Investment Plans and the Trustee.
14.INDEMNITY AND PROTECTIONS
The Trustee and other Indemnified Parties (each as such and in its individual capacity) are
provided with comprehensive indemnity and other protections in the Trust Deed as described
in the Trust Deed.
9.REVOCATION
15.GOVERNING LAW
The Plan Participants may give notice of revocation of that portion of the Trust as constituted
by the Sub-fund to the Trustee at any time, in which case the Trustee will surrender to the
Insurance Company each Policy allocated to the Sub-fund established in relation to the Plan
Participants, and upon receipt by the Trustee of any funds from the Insurance Company in
relation to such Policies shall distribute the net proceeds to the Plan Participants.
This agreement is created under and shall be governed by and construed and enforced
in accordance with the laws of the Cayman Islands (without regard to conflict of laws
principles), which may include the requirement to report certain personal information to
other jurisdictions.
The payment, and timing of payments to the Plan Participants following a revocation, will
depend upon the redemption value of each, the receipt of funds in respect thereof from the
Insurance Company and compliance with applicable law.
16. SUBJECT TO ACCEPTANCE
This Subscription Agreement (which in its entirety consists of pages 1 through 5 hereof)
is subject to acceptance by the Trustee and will not be effective unless and until accepted
by the Trustee. Such acceptance of this Subscription Agreement by the Trustee shall be
evidenced exclusively by the Trustee’s countersignature of this Subscription Agreement.
IN WITNESS WHEREOF THIS SUBSCRIPTION AGREEMENT HAS BEEN EXECUTED AND DELIVERED AS A DEED by each Plan Participant on the ____ day of _______, 20________
(EN FE DE LO CUAL ESTE ACUERDO DE SUSCRIPCIÓN SE HA EJECUTADO Y ENTREGADO COMO UN CONTRATO por cada participante del plan a partir del)
PRINT NAME HERE – THE FIRST PLAN PARTICIPANT / Nombre del Primer Participante del Plan
PRINT NAME HERE – JOINT PLAN PARTICIPANT / Nombre del Co-Participante del Plan
Signed by / Firmado por,
Signed by / Firmado por,
–5–
M.
INDEPENDENT INTRODUCER DETAILS /
Detalles del Introductor Independiente
DECLARATION OF INDEPENDENT INTRODUCER / Declaración de Introductor Independiente
1. I certify that I was introduced to the Plan Participant(s) on the following date:
Certifico que conozco a el/los Participantes(s) del Plan desde la siguiente fecha:
Year and Month /
Año y Mes
2. I certify that I have seen and verified the contents of the original identification documents provided with this Subscription Agreement.
Certifico que yo he visto y verificado los documentos de identificación originales provistos en este Acuerdo de Subscripción.
3. I confirm that I have explained to the Plan Participant(s) the requirements and the need for completing, the Source of Funds, the Medical Questionnaire and the Declaration (together, the
“Associated Documents”).
Confirmo que le he explicado a el/los titulares de la póliza los requisitos y la necesidad de completar el Cuestionario de Origen de los Fondos, el Cuestionario Médico y la Declaración
(juntos, los “Documentos Asociados”).
4. I also confirm that I have taken reasonable steps to ensure that the funding is legitimate, and where sourced from the Plan Participant’s earnings is in line with the proposed Plan
Participant’s income.
Confirmo que he tomado las medidas necesarias para asegurar que los fondos utilizados en este Acuerdo de Subscripción sean legítimos, y que cuando provienen de los ingresos de el/los
Participante(s) del Plan estén de acuerdo con sus ingresos.
5. I declare that to the best of my knowledge, all the information provided with this Subscription Agreement is true and complete and that I will provide further information if required.
Declaro que hasta donde llega mi conocimiento toda la información proporcionada en este Acuerdo de Subscripción es verdadera y completa, y que proporcionaré más información en caso
de ser requerido.
6. I enclose the Subscription Agreement and the related documents (including the Associated Documents) duly completed in original or certified form, and confirm that the signature(s)
contained in the Subscription Agreement and the related documents are signed by the Persons they purport to be.
Envío el Acuerdo de Subscripción y los documentos relacionados (incluyendo los Documentos Asociados) debidamente completados en original o certificados, y confirmo que la(s) firma(s)
contenida(s) en este Acuerdo de Subscripción y en los documentos relacionados fueron firmados por las personas indicadas.
7. This Subscription Agreement was executed by the Plan Participant(s) in my presence.
Este Acuerdo de Subscripción fue ejecutado por el/los Participante(s) del Plan en mi presencia.
PRINT NAME OF INTRODUCER / NOMBRE DEL INTRODUCTOR
INTRODUCER CODE / CÓDIGO DEL INTRODUCTOR
SIGNATURE OF INTRODUCER / FIRMA DEL INTRODUCTOR
DATE / FECHA
DD / MM / AAAA
–6–
FORM IP142-2
v er s i on 05/2015
A D D /RE MOV E
A U T H O R IZ E D PE RS ON
www.investors-trust.com
AGREGAR/REMOVER PERSONA AUTORIZADA
PLAN PARTICIPANT INFORMATION / INFORMACIÓN DEL PARTICIPANTE DEL PLAN
1
PLAN PARTICIPANT’S NAME
NOMBRE DEL PARTICIPANTE DEL PLAN
DATE
FECHA
JOINT PLAN PARTICIPANT’S NAME
NOMBRE DEL CO-PARTICIPANTE DEL PLAN
POLICY NUMBER
NÚMERO DE PÓLIZA
DD / MM / AAAA
ADD NEW AUTHORIZED PERSON / AGREGAR NUEVA PERSONA AUTORIZADA
2
Important Notice / Aviso Importante
The Plan Participant(s) hereby understand(s) and agree(s) that / El participante del plan por la presente entiende y está de acuerdo con:
1. The Authorized Person will have the authority to approve and sign any request related to the Policy, either online or in paper. / La persona autorizada tendrá autoridad para aprobar y firmar cualquier petición
relacionada con la póliza, ya sea en el sitio web o mediante formularios.
2. The Authorized Person is bound to the Plan Participant(s); therefore, the Authorized Person will have access and authority to all Policies, Accounts, Loans and Contracts the Plan Participant(s) may have with
Investors Trust Assurance SPC. / La persona autorizada está vinculada al participante del plan, por lo tanto la persona autorizada tendrá acceso y permiso a todas las pólizas, cuentas, préstamos y contratos
que el participante del plan pueda tener con Investors Trust Assurance SPC.
RELATIONSHIP TO PLAN PARTICIPANT
RELACIÓN CON EL PARTICIPANTE DEL PLAN
FIRST NAME /
Primer Nombre
LAST NAME /
Apellido
COUNTRY OF NATIONALITY /
País de Nacionalidad
PASSPORT / ID # /
No. de Pasaporte
DD / MM / AAAA
GENDER / Género
MALE
Masculino
FEMALE
Femenino
DD / MM / AAAA
TYPE OF ADDRESS / Tipo de Dirección
BUSINESS
Comercial
RESIDENTIAL
Residencial
STATE OR PROVINCE / Estado o Provincia
CITY / Ciudad
MOBILE TELEPHONE / Teléfono Móvil
COUNTRY CODE /
Código del País
AREA CODE /
Código de Área
AREA CODE /
Código de Área
DD / MM / AAAA
ADDRESS / Dirección
ZIP CODE / Codigo postal
COUNTRY / País
COUNTRY CODE /
Código del País
PHONE NUMBER /
Número de Teléfono
AREA CODE /
Código de Área
PHONE NUMBER /
HOME TELEPHONE / Teléfono de Residencia
COUNTRY CODE /
Código del País
MIDDLE NAME /
Segundo Nombre
COUNTRY CODE /
Código del País
PHONE NUMBER /
AREA CODE /
Código de Área
PHONE NUMBER /
E-MAIL /
Correo Electrónico
OCCUPATION /
Ocupación
Required Supporting Documents: A clear copy of a valid Identification Document (ex: passport, government ID, etc.) and Proof of Address (ex: Utility Bill, Bank Statement, etc.) for the Authorized Person
no more than 3 months old. If the Authorized Person is not a director please provide documents proving the relation between the Authorized Person and the organization (ex: Power of Attorney, Board of
Directors Appointment, etc.) / Documentos de soporte requeridos: Una copia legible de un Documento de Identificación válido que contenga la firma de la persona (ej. Pasaporte, Documento de Identidad
Gubernamental, etc.) y Prueba de Residencia (ej. Factura de Servicios, Estado de Cuenta bancario, etc.) No mayor a los 3 meses de antiguedad.
The Authorized Person will be able to review and manage business information online in ITA’s secure Account Access Website. To set-up an online web user account to access this website / La Persona Autorizada podrá revisar
y administrar toda la información comercial en la página de Acceso Privado de Investors Trust. Para poder configurar un usuario en línea y acceder a este sitio web, existen dos opciones:
The Authorized Person will personally register and set-up his/her Web User online. / La Persona Autorizada deberá el mismo registrarse y configurar en línea su usuario.
The Introducer requests ITA to set his/her Authorized Person’s User ID to be / El Introductor solicita a ITA que establezca un usuario para la Persona Autorizada a ser:
REMOVE AUTHORIZED PERSON / REMOVER PERSONA AUTORIZADA
3
Indicate the name of the Authorized person to be removed / Indicar el nombre de la Persona Autorizada que será removida
LAST NAME /
Apellido
FIRST NAME /
Primer Nombre
MIDDLE NAME /
Segundo Nombre
SIGNATURE(S) / FIRMA(S)
4
PLAN PARTICIPANT’S SIGNATURE
FIRMA DEL PARTICIPANTE DEL PLAN
JOINT PLAN PARTICIPANT’S SIGNATURE
FIRMA DEL C0-PARTICIPANTE DEL PLAN
NEW AUTHORIZED PERSON’S SIGNATURE
FIRMA DE LA NUEVA PERSONA AUTORIZADA
INTRODUCER’S SIGNATURE
FIRMA DEL INTRODUCTOR
INTRODUCER CODE
CÓDIGO DEL INTRODUCTOR
Copyright © 2015 Investors Trust Assurance SPC
Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated “Secure” by A.M. Best Company. For the latest rating, access www.ambest.com. Investors Trust Assurance SPC is a member of The Association of International Life Offices (AILO). For
more information, please visit: www.investors-trust.com.
If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your
servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands.
LA TRADUCCIÓN DE ESTE DOCUMENTO A OTRO IDIOMA DISTINTO AL INGLES, TIENE EL ÚNICO PROPÓSITO DE FACILITAR LA COMPRENSIÓN DE DICHO DOCUMENTO A INDIVIDUOS QUE NO TIENE CONOCIMIENTO DEL IDIOMA INGLES. NUESTRA INTENCIÓN ES DE PROVEER LA TRADUCCIÓN MAS PRECISA
POSIBLE DEL DOCUMENTO ORIGINAL EN INGLES, PERO DADO A DIFICULTADOS DE INTERPRETACIÓN, PUEDEN EXISTIR PEQUEÑAS DISCREPANCIAS DE LENGUAJE. NO ASUMIMOS RESPONSABILIDAD POR LA PRECISIÓN DE LA TRASCRIPCIÓN, Y DECLINAMOS LA OBLIGACIÓN ANTE CUALQUIER RECLAMO.
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add/remove
authorized person
Ve r s i o n 0 5 / 2 0 1 5
FORM IG132-2
v er s i on 05/2015
S O U R C E O F F U N D S Q U E S T I O N N AI R E
Cuestionario de Origen de los Fondos
To be completed by ALL cases with a Premium of USD$ / EUR€ / GBP£ 10,000 or above.
Questionnaire will be valid for a period of 3 years only. After that period, a new questionnaire will be required.
Para ser completado en TODOS los casos de Contribuciones de USD$ / EURO€ / GBP£ 10.000 o mayor.
El cuestionario será valido únicamente por un período de 3 años. Al finalizar ese período, se requerirá un nuevo cuestionario.
1
PLAN
w wPARTICIPANT’S
w . i n NAME
vesto
rs-trust.com
DATE
FECHA
DD / MM / AAAA
POLICY NUMBER
NÚMERO DE PÓLIZA
QUESTIONNAIRE / CUESTIONARIO
2
THIS QUESTIONNAIRE IS BEING COMPLETED FOR / ESTE CUESTIONARIO ESTÁ SIENDO COMPLETADO PARA:
FIRST PLAN PARTICIPANT /
JOINT PLAN PARTICIPANT /
PAYOR (if other than the Plan Participant(s))
PRIMER PARTICIPANTE DEL PLAN
CO-PARTICIPANTE DEL PLAN
PAYOR’S NAME / NOMBRE DEL PAGADOR:
PAGADOR (en caso que no sea el Participante del Plan)
‡ Please note that the company requires one Source of Fund Questionnaire per Plan Participant and one for each Payor, if other than Plan Participant(s). Therefore, additional forms should be submitted for each person when applicable.
Tenga en cuenta que la empresa requiere un Cuestionario de Origen de Fondos por cada uno de los Participante del Plan y uno por cada Pagador (en caso que fuese diferente al Participante del Plan). Por lo tanto, formularios adicionales deberán ser enviados para cada
persona en caso que fuese necesario.
A) Please indicate annual income of the person or entity completing this questionnaire / Por favor indique el salario/ingreso anual de la persona o entidad completando este cuestionario:
Below USD 25,000 / Menor de USD 25.000
USD 50,000 to USD 100,000 / USD 50.000 a USD 100.000
USD 500,000 and above / Mayor de USD 500.000
B) If this questionnaire is being completed for a corporation, who are the current directors and shareholders, and do any holding companies and subsidiaries exist? / Si este cuestionario está siendo completado por
una corporación, por favor indicar quienes son los directores y accionistas actuales, y si existe alguna compañía controladora o subsidiaria.
C) If this questionnaire is being completed for a trust, please advise the identity of the parties / Si este cuestionario está siendo completado para un Fideicomiso (Trust), por favor indicar la identidad de las partes:
D) Is the person or entity completing this questionnaire, currently or has been in the past, one of the following: (A) A senior military, governmental, or political official in a non-US
YES / SI
country, or (B) Closely associated with or an immediate family member of such official? / Indique si la persona o entidad completando este cuestionario es actualmente o fue: (A) un militar de
alto rango, funcionario gubernamental o político de un país distinto a los EE.UU., ó (B) está estrechamente asociada con un funcionario de dichas características o es un miembro de su familia inmediata?
NO
If Yes, please provide details: / Si respondió afirmativamente, favor proveer detalles a continuación:
E) Bank information of the person or entity completing this questionnaire / Información Bancaria de la persona o compañía completando este cuestionario:
NAME OF BANK / Nombre del Banco:
ACCOUNT NUMBER / Número de Cuenta:
DATE OPENED / Fecha de Apertura:
DD / MM / AAAA
BANK’S ADDRESS / Dirección:
F) Please indicate how the funds have been obtained for this investment: / Por favor indicar cómo se obtuvieron los fondos para esta inversión:
SALE OF PROPERTY OR
OTHER ASSETS
VENTA DE PROPIEDADES
U OTROS ACTIVOS
CURRENT INCOME
INGRESO/ SALARIO
INVESTMENT GAIN / LOAN / SAVING
GANANCIA PROVENIENTE
DE INVERSIÓN / PRÉSTAMO / AHORROS
COMPENSATION PAYMENT / MATURING
INVESTMENT / POLICY CLAIM
PAGO COMPENSATORIO / MADURACIÓN DE INVERSIÓN /
RECLAMO DE PÓLIZA
WINNINGS
INHERITANCE
GIFT
PREMIO
HERENCIA
REGALO
Please provide details and required documentation for any boxes checked above / Por favor proveer detalles sobre las respuestas seleccionadas arriba:
G) Is the person or entity completing this questionnaire either: (A) a U.S. citizen and/or resident for tax reporting purposes, or (B) a UK resident for tax reporting purposes?
¿Es la persona completando este cuestionario: (A) un ciudadano y/o residente de los EE.UU. para efectos fiscales, ó (B) un residente del Reino Unido para efectos fiscales?
If Yes, please provide the appropriate information below: / Si respondió afirmativamente, favor proveer la información apropiada a continuación:
A) U.S. Tax Identification Number
Número de Identificación Fiscal de los EE.UU.
YES / SI
NO
YES / SI
NO
B) UK National Insurance Number
Número del Seguro Nacional del Reino Unido
H) What is the purpose of this investment, (Retirement, education, etc.): / ¿Cuál es el propósito de esta inversión, (retiro, educación, etc)? Por favor indicar:
I) Have the address(es) of the person or entity completing this questionnaire changed during the past three years, or since the inception of policy, whichever is greater? (existing Policies only)
¿La persona o entidad que completa este cuestionario ha cambiado la dirección durante los últimos tres años o desde el inicio de la póliza? (para Pólizas existentes únicamente)
If Yes, please complete and provide form “IP100-1 Customer Service Request” to note any change of address. / Si respondió afirmativamente, por favor complete y envíe el formulario “IP100-2 Solicitud de Servicio al Cliente” para cualquier cambio de dirección.
DECLARATION / DECLARACIÓN
3
I/We, the undersigned, as Plan Participants(s) and the Payor, if other than Plan Participant(s), hereby certify that all the informationI provided
N V E S T Oabove
R S
TisRtrue
U S Tand correct.
Yo/Nosotros, el/los suscrito(s), como Participante(s) del Plan y Pagador (en caso que fuese diferente al Participante del Plan) declaro(amos) que toda la información provista anteriormente es verdadera y correcta.
PAYOR’S SIGNATURE (if other than Plan Participant(s)) / FIRMA DEL PAGADOR (en caso que fuese diferente al Participante del Plan)
4
SIGNATURE /
FIRMA
5
FIRMA DEL CO-PARTICIPANTE DEL PLAN
INTRODUCER CODE
Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated “Secure” by A.M. Best Company. For the latest rating, access www.ambest.com. Investors Trust Assurance SPC is a member of The Association of
International Life Offices (AILO). For more information, please visit: www.investors-trust.com.
If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United
States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands.
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source of funds
questionnaire
Ve r s i o n 0 5 / 2 0 1 4
FORM IN110-2
v er s i on 05/2015
I N S U R E D P E R S O N / A S E G U R AD O ( A)
PLEASE COMPLETE ONE FORM PER INSURED PERSON
POR FAVOR COMPLETE UN FORMULARIO POR CADA PERSONA ASEGURADA
DATE
FECHA
POLICY NUMBER
NÚMERO DE PÓLIZA
DEL PARTICIPANTE DEL PLAN
1 NOMBRE
DD / MM / AAAA
De forma predeterminada, si la Póliza tiene un solo Participante del Plan, él o ella será el/la único(a) Asegurado(a) en la Póliza. Si la Póliza tiene dos Participantes del Plan, ambos titulares serán los Asegurados en la Póliza. Sin embargo, el/los Participante(s) del Plan puede(n)
nombrar a una persona que no sea a sí mismos como el Asegurado. Si hay más de un Asegurado indicado en las Páginas de Datos de la Póliza, el Beneficio por Defunción será pagado únicamente luego del deceso del último Asegurado sobreviviente y solo un Beneficio por Defunción
deberá ser pagado. La compañía requiere que cada uno de los Asegurados completen el formulario IN110, por lo tanto, un formulario adicional deberá ser presentado si existiese un segundo Asegurado en la Póliza.
INSURED PERSON (select only one) / ASEGURADO(A) (seleccione sólo uno)
2
PARTICIPANTE DEL PLAN
DESIGNE A UNA NUEVA PERSONA COMO ASEGURADO(A)
(Por favor complete la sección 2b de esta solicitud)
ADD NEW INSURED PERSON (if applicable) / AGREGAR UNA NUEVA PERSONA COMO ASEGURADO (si aplica)
2b
Insured Person Information / Información del Asegurado
LAST NAME /
Apellido
FIRST NAME /
Primer Nombre
COUNTRY OF NATIONALITY / País de Nacionalidad
DD / MM / AAAA
PASSPORT / ID # / No. de Pasaporte
GENDER / Género
MALE
Masculino
FEMALE
Femenino
TYPE OF ADDRESS
BUSINESS
Comercial
CITY / Ciudad
MIDDLE NAME /
Segundo Nombre
RESIDENTIAL
Residencial
DD / MM / AAAA
DD / MM / AAAA
COUNTRY / País
AREA CODE /
COUNTRY CODE /
Código de Área
Código del País
PHONE NUMBER /
COUNTRY CODE /
Código del País
AREA CODE /
Código de Área
PHONE NUMBER /
AREA CODE /
COUNTRY CODE /
Código de Área
Código del País
PHONE NUMBER /
AREA CODE /
COUNTRY CODE /
Código de Área
Código del País
PHONE NUMBER /
E-MAIL /
Correo Electrónico
OCCUPATION /
Ocupación
Documentos de soporte requeridos por parte de la persona asegurada: una copia legible de un Documento de Identificación válido que contenga la firma de la persona (ej. Pasaporte, Documento de Identidad Gubernamental, etc.) y una Prueba de Residencia (ej.
Factura de Servicios, Estado de Cuenta bancario, etc.) que no tenga más de 3 meses de antigüedad.
MEDICAL QUESTIONNAIRE FOR INSURED PERSON / CUESTIONARIO MÉDICO DE LA PERSONA ASEGURADA
3
A) ¿Ha usted alguna vez solicitado una póliza de seguro que haya sido restringida, declinada o rechazada?
SI
NO
SI
SI
NO
NO
C) ¿Usted ha sido diagnosticado o tratado por un profesional médico por el Síndrome de Inmunodeficiencia adquirido (SIDA) o cualquier complicación relacionada a este?
SI
NO
D) ¿Ha usted participado o tiene intenciones de participar en algún deporte o actividad riesgosa incluyendo pero no limitado a: paracaidismo, parapente, ala delta, vuelo en planeadores, globos
SI
NO
B) ¿Usted alguna vez ha sido diagnosticado o tratado para algunas de las siguientes condiciones?
i. Enfermedad o trastorno del corazón, arterias, venas, sistema cardiovascular, embolia, presión alta, tumores, cáncer o diabetes.
ii. ¿Algún otro trastorno psicofísico no mencionado anteriormente?
aerostáticos o aviones ultraligeros, o cualquier otro vuelo que no sea como pasajero en un vuelo comercial regular, buceo, snorkeling, automovilismo o motociclismo de competición o recreación?
E) Si respondió afirmativamente a cualquiera de estas preguntas, favor proveer detalles a continuación (incluyendo si correspondiese el nombre, dirección y teléfono/fax de su/s médico/s). Si es necesario,
anexe una hoja adicional.
ADDITIONAL INFORMATION / INFORMACIÓN ADICIONAL
4
Indique si la Persona Asegurada es actualmente o fue: (A) un militar de alto rango, funcionario gubernamental o político de un país distinto a los EE.UU., ó (B) está
estrechamente asociada con un funcionario de dichas características o es un miembro de su familia inmediata.
SI
NO
Si respondió afirmativamente, favor proveer detalles a continuación:
I/We, the undersigned, as Plan Participant(s) and Insured, if other than Plan Participant(s), hereby certify that all the information provided
above is true and correct.
I N V E S T O R S T R U S T
5
Yo/Nosotros, el/los que firma(n) el presente documento como Participante(s) del Plan y Asegurado(s), en caso de no ser el/los Participante(s) del Plan, certifico(amos) que toda la información provista es verdadera y correcta.
INSURED SIGNATURE (if other than Plan Participant(s)) / FIRMA DEL ASEGURADO (en caso de no ser el/los Participante(s) del Plan)
6
SIGNATURE
FIRMA
7
INTRODUCER CODE
If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United
States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands.
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N V E S T O R S
T
R U S T
insured person
Ve r s i o n 0 5 / 2 0 1 5
FORM IP114-2
v er s i on 05/2015
P AY M E N T A U T H O R IZ AT ION
AU T O R IZA C IÓ N DE PA GO
Complete this Form to Select or Update Payment Information
Complete este Formulario para Seleccionar o Actualizar la información de Pago
1
NOMBRE DEL
w PARTICIPANTE
w w . i nDELvPLAN
es
DATE
FECHA
tors-trust.com
DD / MM / AAAA
POLICY NUMBER*
NÚMERO DE PÓLIZA*
PAYMENT INFORMATION / INFORMACIÓN DE PAGO
Please check one / Por favor seleccione una opción:
a. By checking this box, I authorize Investors Trust to make a one-time debit only from my account (credit card or bank account) for the amount of
Selecciono esta opción para autorizar a Investors Trust a realizar un cargo único a mi cuenta (tarjeta de crédito o cuenta bancaria) por la cantidad de
2
SELECT CURRENCY
Seleccione la moneda
ENTER ONE-TIME CONTRIBUTION AMOUNT
Introduzca monto para un cargo único
USD $
EUR €
GBP £
,
.
b. By checking this box, I authorize Investors Trust to debit from my account (credit card or bank account) or Flex Plan policy all future scheduled contribution payments to my investment plan.
Selecciono esta opción para autorizar a Investors Trust a debitar de mi cuenta (tarjeta de crédito o cuenta bancaria) o de la póliza Flex Plan, los futuros cargos recurrentes de contribuciones programadas a mi plan de inversión.
c. By checking this box, I authorize Investors Trust to debit from my account (credit card or bank account) or Flex Plan policy all pending and future scheduled contribution payments to my investment plan.
Selecciono esta opción para autorizar a Investors Trust a debitar de mi cuenta (tarjeta de crédito o cuenta bancaria)o de la póliza Flex Plan, todos los  cargos pendientes y futuros cargos recurrentes de contribuciones programadas a mi plan de inversión.
PAYMENT FRECUENCY (To be completed if 2b or 2c is selected) / FRECUENCIA DE PAGO (Para ser completado si la opción 2b o 2c ha sido seleccionada)
ANNUALLY
ANUAL
3
SEMI-ANNUALLY
SEMESTRAL
QUARTERLY
TRIMESTRAL
MONTHLY (CREDIT CARD, DIRECT DEBIT or FLEX DEBIT ONLY)
MENSUAL (Tarjeta de crédito, débito directo y débito del Flex Plan únicamente)
PAYOR INFORMATION /INFORMACION DEL PAGADOR
4
PLAN PARTICIPANT
PARTICIPANTE DEL PLAN
JOINT PLAN PARTICIPANT
OTHER (Please complete Addendum, section A)
OTROS (Por favor complete el anexo, sección A)
PAYMENT METHOD / MÉTODO DE PAGO
CHECK OR WIRE TRANSFER / CHEQUE Ó TRANSFERENCIA ELECTRÓNICA
5
5a
The company will send an e-mail notification prior to the due date of your next payment. / La Compañía enviará notificaciones por correo electrónico previo a la fecha de vencimiento de su próxima contribución.
CREDIT CARD / TARJETA DE CRÉDITO
5b
CREDIT CARD NUMBER / NÜMERO TARJETA DE CRÉDITO
CREDIT CARD TYPE / TIPO DE TARJETA DE CRÉDITO
American Express
Visa
Discover
Diners Club
MasterCard
JCB
EXPIRATION DATE / FECHA DE VENCIMIENTO
†Please note that credit cards like Visa, MasterCard, & American Express will be charged according to the currency of the product, and all other credit cards will be billed in U.S. Dollars. Credit card debits are limited to amounts below USD 25,000 (or the equivalent amount in
EUR or GBP. †Por favor notar que Tarjetas de Crédito como Visa, MasterCard, y American Express, serán cargadas de acuerdo a la moneda del producto, y todas las otras Tarjetas de Crédito serán facturadas en dólares US. Los débitos de tarjeta de crédito están limitados a montos inferiores
a USD 25.000 (o equivalente en EUR o GBP).
DIRECT DEBIT FROM US BANK ACCOUNT / DÉBITO DIRECTO DESDE CUENTA DE CHEQUES
5c
As a convenience to me, I hereby request and authorize Investors Trust Assurance, SPC (the “Company”) to withdraw the amount indicated from the banking account entered below. If any withdrawal is not honored by the banking institution (the “Bank”) whether with
or without cause and whether intentionally or inadvertently, the Bank shall be under no liability whatsoever and I may be responsible for a returned check fee. I agree that the Bank’s rights in respect to such draft shall be the same as if it were a check drawn on the
bank and signed personally by me. Should any draft not be honored by the Bank upon presentation, I understand that this method of payment may be terminated. I understand also that my policy may lapse if said draft is returned unpaid by the Bank or discontinue
payments prior to receiving confirmation of the draft processing from the Company.
Como conviene a mi persona, solicito y autorizo a Investors Trust Assurance, SPC (la “Compañía) a debitar la cantidad indicada de la cuenta bancaria ingresada a continuación. Si el débito no es aceptado por la institución bancaria (el “Banco”) ya sea con o sin causa
y ya sea intencional o inadvertidamente, el Banco no tendrá ninguna responsabilidad en absoluto y yo puedo ser responsable por el cargo de la transacción devuelta. Estoy de acuerdo que los derechos del Banco en respecto a tal giro serán igual que como si fuera un
cheque girado sobre el banco y firmado por mí. Si cualquier giro no fuese honrado por el Banco a la hora de su presentación, yo entiendo que este método de pago podría ser cancelado. Yo también entiendo de que mi Póliza puede caducar si tal giro es devuelto por el
Banco o si los pagos son descontinuados antes de recibir confirmación del procesamiento del giro de parte de la Compañía.
ACCOUNT NUMBER / NÚMERO DE CUENTA
ROUTING OR ABA NUMBER / NÚMERO DE ABA
(attach void check on Addendum, section B / adjunte un cheque anulado en el anexo, sección B)
†EURO/GBP amounts will be debited in U.S. Dollars, subject to conversion rate as posted on the website. This service is only available via U.S. banks. Direct debit from US bank accounts are limited to amounts below USD 100,000. / Montos en EUR/GBP serán debitados
en dólares US, de acuerdo a la tasa de conversión publicada en la página web. Este servicio está disponible solo a través de bancos en los Estados Unidos. Se aceptan débitos directos de cuentas de bancos de EE.UU. por cantidades menores a USD 100.000.
FLEX PLAN DEBIT / DÉBITO DEL FLEX PLAN
5d
ENTER THE POLICY NUMBER TO BE DEBITED / INGRESE EL NÚMERO DE PÓLIZA A SER DEBITADA
T
S
P
Flex Plan debits are only allowed for automatic recurring payments (Either 2b or 2c must be selected). One -time debits (2a) from a Flex Plan are not allowed; the plan participant(s) must submit Form IP120 - Surrender Request.
Débitos del Flex Plan solo están permitidos para débitos automáticos recurrentes (Opción 2b o 2c deben ser seleccionadas). Débitos únicos (2a) del Flex Plan no están permitidos; el participante(s) del plan debe enviar el formulario IP120 - Surrender Request.
Transaction Cost: A surcharge may apply depending on the payment method selected. Please review form IG138-1 or IG140-1 for more details.
Costo de Transacción: Un cargo podrá ser aplicado dependiendo de la tarjeta de crédito y del producto de inversión seleccionado. Por favor revise el formulario IGI38-2 o IG140-2 para más detalles.
6
FIRMA DEL C0-PARTICIPANTE DEL PLAN
*If the action requested herein involves a Capital Redemption product, the term “Contract” shall be deemed to be substituted for the term “Policy” wherever the term “Policy” appears in this document.
*Si la acción solicitada en este documento involucra al producto de Capital Redemption, el término “contrato” se considerará que se sustituya por el término “Póliza” siempre que el término “Póliza” aparezca en este documento.
Investors Trust Assurance SPC is a Cayman Islands insurance company providing a variety of offshore wealth management solutions to investors around the world. These solutions support successful and vibrant retirement investment portfolios. Investors Trust works exclusively through independent financial advisers. Investors
Trust is a registered trademark of Investors Trust Assurance SPC. Investors Trust Assurance SPC is regulated by the Cayman Islands Monetary Authority. For more information, please visit: www.investors-trust.com.
If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd
Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands.
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payment authorization
Ve r s i o n 0 5 / 2 0 1 5
FORM IP114-2
v er s i on 05/2015
P AY M E N T A U T H O R IZ AT ION
AU T O R IZA C IÓ N DE PA GO
Addendum / Anexo
PAYOR INFORMATION / INFORMACIÓN DEL PAGADOR
A
RELATIONSHIP TO PLAN PARTICIPANT
RELACIÓN CON EL PARTICIPANTE DEL PLAN
FIRST NAME / Primer Nombre
COUNTRY OF NATIONALITY / País de Nacionalidad
DD / MM / AAAA
PASSPORT / ID # / No. de Pasaporte
GENDER / Género
MALE /
Masculino
FEMALE /
Femenino
TYPE OF ADDRESS / Tipo de Dirección
BUSINESS /
Comercial
RESIDENTIAL /
PASSPORT / ID DATE OF ISSUE / Fecha de Emisión
DD / MM / AAAA
PASSPORT / ID DATE OF EXPIRY / Fecha de Expiración
DD / MM / AAAA
Residencial
CITY / Ciudad
COUNTRY / País
AREA CODE /
Código de Área
PHONE NUMBER /
AREA CODE /
COUNTRY CODE /
Código de Área
Código del País
PHONE NUMBER /
COUNTRY CODE /
Código del País
MIDDLE NAME / Segundo Nombre
COUNTRY CODE /
Código del País
AREA CODE /
Código de Área
PHONE NUMBER /
COUNTRY CODE /
Código del País
AREA CODE /
Código de Área
PHONE NUMBER /
E-MAIL /
Correo Electrónico
OCCUPATION /
Ocupación
PAYOR’S SIGNATURE (if different from Plan Participant(s))
FIRMA DEL PAGADOR (en caso que sea diferente al Participante del Plan)
ATTACH VOID CHECK OR DEPOSIT SLIP HERE
INCLUYA EL CHEQUE ANULADO Ó LA PLANILLA DE DEPOSITO
B
Investors Trust Assurance SPC is a Cayman Islands insurance company providing a variety of offshore wealth management solutions to investors around the world. These solutions support successful and vibrant
retirement investment portfolios. Investors Trust works exclusively through independent financial advisers. Investors Trust is a registered trademark of Investors Trust Assurance SPC. Investors Trust Assurance SPC is
regulated by the Cayman Islands Monetary Authority. For more information, please visit: www.investors-trust.com.
If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to
United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands.
LA TRADUCCIÓN DE ESTE DOCUMENTO A OTRO IDIOMA DISTINTO AL INGLES, TIENE EL ÚNICO PROPÓSITO DE FACILITAR LA COMPRENSIÓN DE DICHO DOCUMENTO A INDIVIDUOS QUE NO TIENE CONOCIMIENTO DEL IDIOMA INGLES. NUESTRA INTENCIÓN ES DE PROVEER LA TRADUCCIÓN MAS PRECISA
POSIBLE DEL DOCUMENTO ORIGINAL EN INGLES, PERO DADO A DIFICULTADOS DE INTERPRETACIÓN, PUEDEN EXISTIR PEQUEÑAS DISCREPANCIAS DE LENGUAJE. NO ASUMIMOS RESPONSABILIDAD POR LA PRECISIÓN DE LA TRASCRIPCIÓN, Y DECLINAMOS LA OBLIGACIÓN ANTE CUALQUIER RECLAMO.
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payment authorization
Ve r s i o n 0 5 / 2 0 1 5
Addendum
FOR M IN100-2
v er s i on 05/2015
C L IEN T A C C E P TA N C E D E C L ARAT ION
C A R TA D E C O MP R O MI S O D E I N VER SI Ó N
w ww ww .wi .n i vn ev se t sot rosr -st -r tur su t s. tc . oc mo m
To be completed by the Applicant(s). Please read the policy details prior to completing this form.
To be completed for ALL Regular Premium cases of USD$ / EUR€ / GBP£ 10,000 or greater.
Para ser completado por el/los Participante(s) del Plan. Por favor lea los detalles de la póliza antes de completar este formulario.
Para ser completado en TODOS los casos de Contribuciones Regulares mayores a USD$ / EUR€ / GBP£ 10,000.
1
DATE
FECHA
DD / MM / AAAA
2
a. POLICY/ LOAN
DEAR CLIENT
ESTIMADO CLIENTE:
Please read the following statements carefully in order to ensure your investment privileges.
Por favor lea detalladamente las siguientes declaraciones para asegurar sus privilegios de inversión.
I/WE, THE PLAN PARTICIPANT(S) AS INDICATED ABOVE, UNDERSTAND AND ACKNOWLEDGE: / YO/NOSOTROS, EL/LOS PARTICIPANTE(S) DEL PLAN ARRIBA MENCIONADO, ENTIENDO(EMOS) Y DECLARO(MOS):
INTRODUCER NAME / NOMBRE DEL INTRODUCTOR
1. My independent Introducer,
, has explained to me the charges and fees associated with this Policy. I/We have reviewed
this Subscription Agreement and all other relevant information contained in the illustration and product brochure. Mi Introductor_______, me/nos ha explicado la estructura de los cargos y costos
asociados con esta Póliza. Yo/Nosotros he(mos) revisado el Acuerdo de Suscripción y toda la información relevante contenida en la Ilustración y el folleto del producto.
Select currency
Seleccione la moneda
2. This Subscription Agreement is for the purpose of investing in a Policy with an annual Premium of
Este Acuerdo de Subscripción tiene como fin la inversión en una Póliza con contribuciones anuales de
Enter annual premium amount
Ingrese el monto de la contribución anual
USD $
EUR €
GBP £
,
.
Policy Term
Término de la Póliza
3. This is a
Poliza de
5 years/años
10 years/años
15 years/años
20 years/años
25 years/años
Regular Premium Policy that requires me/us to make annual contributions during the entire life of the Policy.
de contribuciones regulares que requiere que realice(mos) contribuciones anuales durante todo el término de la Póliza.
4. The cost structure of the Policy includes the monthly Policy Fee, monthly Asset Management Fee and annual Administration Charge.
La estructura de cargos de la Póliza incluye el Cargo de la Póliza mensual, el Cargo de Administración de Inversiones mensual y el Cargo de Administración anual.
5. The Policy may have little to zero surrender value, due to Surrender Charges, if the Policy is surrendered during the early years of the Policy life.
La Póliza podría no tener o tener un muy bajo valor de rescate, debido a los Cargos por Rescate, si se realiza un rescate de la Póliza durante los primeros años del término de la misma.
6. This Policy includes a Loyalty Bonus on years 10, 15, 20 and 25, applicable according to the duration (full contribution payment term) of the Policy. However, this bonus will be
forfeited if the terms and conditions as specified by the Company are not met. (There will be no Loyalty Bonus for full contribution payment terms less than 10 years.) Este producto incluye
una Bonificación por Lealtad en los años 10, 15, 20 y 25, la cual será aplicada de acuerdo al término completo de contribución de la Póliza. Sin embargo, esta bonificación se podría perder si los términos y condiciones especificados por la
Compañía no son cumplidos. (No habrá Bonificación por Lealtad en planes con términos de contribución menores a 10 años).
7. This Policy is invested in mutual funds; the returns of which are not guaranteed and depend purely on market performance. (Only applicable plans with these funds selected and
Evolution product.) Esta Póliza invierte en fondos mutuos, los cuales no tienen un rendimiento garantizado y dependen exclusivamente de la rentabilidad del mercado. (Solo aplica para los planes con estos fondos seleccionados y para
los productos Evolution).
8. The Plan Participant(s) indistinctly may be subject to a phone interview performed by the Company for quality control and security purposes.
El/Los Participante(s) del Plan, indistintamente, estará(n) sujeto(s) a una entrevista telefónica realizada por la Compañía por motivos de seguridad y control de calidad.
3
INTRODUCER CODE
I
If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to
United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands.
E O
S TR O
S RTU RS U
N IV NE V
S T
S R T
T S T
client acceptance
declaration
version
05/2015
Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated “Secure” by A.M. Best Company. For the latest rating, access www.ambest.com. Investors Trust
Assurance SPC is a member of the Association of International Life Offices (AILO). The contents are not to be reproduced or distributed to the public or press. Please consult your own
legal, tax or investment professional before making any financial decisions.
Investors Trust es una marca registrada de Investors Trust Assurance SPC, calificada “Segura” por A.M. Best Company. Para obtener la calificación más actualizada, visite www.ambest.com. Investors
Trust Assurance SPC es miembro de la Association of International Life Offices (AILO). Este documento no puede ser reproducido o distribuido al público o prensa. Antes de tomar cualquier decisión
financiera, consulte con un asesor profesional para obtener información sobre regulaciones legales, impuestos y/o planificación financiera.
‡ Third party trademarks are used with the permission of their owners.
‡ Las marcas registradas de terceros son utilizadas con el permiso de sus dueños.
For Inquires write to / Para consultas escriba a:
Investors Trust Assurance SPC,
Suite 4210, 2nd Floor, Canella Court, Camana Bay • PO Box 32203
Grand Cayman, KY1-1208 • Cayman Islands
Or E-mail / Contáctenos por correo electrónico a:
[email protected]

Acuerdo de Subscripción

Transcripción

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