Read Microsoft Word - PAYMENT REQUEST APPLICATION FORM DOC 2 _amended 050511_.DOC text version

PAYMENT REQUEST APPLICATION FORM

Kindly ensure that all the relevant information is provided to facilitate a seamless payment process.

(For Official Use Only) SHORT TERM INVESTMENT PRODUCTS (STIPs)

COMPANY CODE: CLICO BRITISH AMERICAN CONTRACT NO: EFPA MUTUAL FUND AMOUNT:TT$ ...................................................... ACH CHEQUE Date requested: ...................................................

Location: ...................................................................

(If individual, insert First Name and Surname)

(MM/DD/YY)

OWNER: E-MAIL: OWNER: E-MAIL: OWNER: E-MAIL: OWNER: E-MAIL:

Original Valid ID (National ID/Passport/DP) COPY REQUIRED Release of Assignment duly stamped by Board of Inland Revenue (if applicable)

PHONE:

CELL: (If individual, insert First Name and Surname)

PHONE:

CELL: (If individual, insert First Name and Surname)

PHONE:

CELL: (If individual, insert First Name and Surname)

PHONE:

Original policy contract/ certificate (If lost, Declaration of Loss Policy/Certificate Form) Signed and Witnessed Third Party Declaration Form (Commissioner of Affidavit) Signed Deed of Assignment and Declaration of Trust Form or Deed of Trust (to be completed in triplicate) Signature of all parties to policies/certificates where there are Multiple Owners (Where "AND" & "AND/OR" appears on policies/certificates ALL parties must sign)

CELL:

Notarized letter and ID for clients residing abroad Power of Attorney Registered in Trinidad & Tobago (if applicable) Account validation

Signature of one Party to policies/certificates where there are multiple owners (Where "OR" appears on policies/certificates)

Requirements showing name of bank & branch, type of account, account number & accountholder's name (e.g. Copy of recent Bank Statement or Letter from Bank)

PLEASE NOTE THE FOLLOWING FOR ASSIGNED POLICIES/CERTIFICATES ONLY: Assignee must complete a Prior Assignment Form (Schedule II to be completed in quadruplicate) Assignee must indicate the amount of the assignment

PAYMENT INFORMATION

DO YOU OWN A BANK ACCOUNT? YES NO (If yes, please provide the following information)

CHEQUING SAVINGS

NAME OF BANKER: ......................................................................................................................................................................... BRANCH: ......................................................................................................................................................................................... ACCOUNT NUMBER: .......................................................................................................................................................................

NAME OF ACCOUNT HOLDER: .........................................................................................................................................................

I/We certify that all information provided is accurate and authorize the Bankers to credit the Owner(s) account number identified above. (Owner(s) Initials Required) I/We certify that the account information provided above is that of the Owner(s) ONLY. (Owner(s) Initials Required) I/We agree to the processing fee of twentyfour dollars ($24.00) for inaccurate account numbers provided herein and authorize deduction from payment proceeds. (Owner(s) Initials Required)

....................................................................... ................................................................... .......................................... Owner's Name (please print) Owner's Signature ID/DP/Passport No. ....................................................................... ................................................................... .......................................... Owner's Name (please print) Owner's Signature ID/DP/Passport No. ....................................................................... ................................................................... .......................................... Owner's Name (please print) Owner's Signature ID/DP/Passport No. ....................................................................... ................................................................... .......................................... Owner's Name (please print) Owner's Signature ID/DP/Passport No. .............................................................................. ..................................................................................... Authorised Officer's Signature Authorised Officer's Name (please print)

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