APPLICATION FOR SAGICOR LIFESTYLE
Pension Plan
Part A: Client Details
Full Name
*
First Name
Middle Name
Last Name
Alias
*
Maiden Name
*
(If Applicable)
Mother's Maiden Name
(If Applicable)
Marital Status
*
Single
Married
Divorced
Widowed
Sex
*
Male
Female
Date of Birth
*
/
Day
/
Month
Year
Date
Upload a copy of your Birth Certificate
Browse Files
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Choose a file
Cancel
of
Upload a copy of your I.D.
*
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Choose a file
Cancel
of
Upload a copy of your TRN (Tax Registration Number)
*
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Choose a file
Cancel
of
Country of Birth
*
Nationality
*
Jamaican Resident
*
Yes
No
If No, State Country
Since
*
-
Day
-
Month
Year
Date
Country of Citizenship
*
Are you a US Green Card Holder?
*
Yes
No
Have you been present in the US for 31 days during the current year and 183 days during the past 3 years?
*
Yes
No
Tax Identification Number Type
Social Security
Individual Taxpayer ID
Employer ID
Tin Number
Occupation
*
TRN
*
Tax Registration Number
NIS
*
National Insurance Scheme
Residential Address
*
Street
City/Town
*
Country
*
Since
*
/
Day
/
Month
Year
Date
Previous Address
(If at current address five years or less)
City/Town
Country
Mailing Address
(If different from above)
City/Town
Country
Email Address
*
(Telephone) Mobile
*
Format: (000) 000-0000.
Telephone (Home)
Please enter a valid phone number.
Format: (000) 000-0000.
Telephone (Work)
Please enter a valid phone number.
Format: (000) 000-0000.
Next of Kin
Full Name of Next of Kin
*
Current Address
*
Telephone (Work)
Format: (000) 000-0000.
Telephone (Mobile)
*
Please enter a valid phone number.
Format: (000) 000-0000.
For Employed Persons
Name of Current Employer
Address
Tel. No
Format: (000) 000-0000.
Name of Previous Employer
For Self-Employed Persons
Name of Business
Address
Tel. No
Format: (000) 000-0000.
Fax Number
Nature of the Business
Email Address for Business
example@example.com
Website Address
Have you ever engaged in any transaction with Sagicor or any of its Subsidaries?
*
Yes
No
If yes, State type
*
Investment
Insurance
Pensions
Mortgage
Banking
Other
Are you currently contributing to a superannuation fund or a retirement scheme?
*
Yes
No
PART B: CLIENT IDENTIFICATION
Passport No.
Expiry Date
-
Month
-
Day
Year
Date
Country of Issue
Drivers License
Expiry Date
-
Month
-
Day
Year
Date
Country of Issue
National ID
Expiry Date
-
Month
-
Day
Year
Date
Country of Issue:
Other
Please Specify
Date
-
Month
-
Day
Year
Date
Country of Issue
PART C: VERIFICATION OF RESIDENCE
Valid Copy of any of the following must be attached:
Verification of Residential Address (Copy of Document must be attached)
*
Utility or Cable Bill (No more than 3 months old)
Declaration witnessed by J.P.
Bank Statement
Other
Are you or any of your immediate family members (parents, siblings, spouse, children or in-laws) a current or former senior official in the military, executive, legislative or administrative arms of government or judiciary of your country of residence or a foreign government or a senior officer of a foreign political party or a senior executive of an enterprise owned by your country of residence or a foreign government?
*
Yes
No
If yes, provide details
PART D: PLAN DETAIL
Annual Contribution
*
Frequency of Payment
*
Annual
Semi-Annual
Quarterly
Monthly
Mode of Payment
PAP (Pre-Authorized Payment)
Salary Deduction
Cash
Online Payment
Nominated Beneficiary
*
(Trustee required where nominated is a minor or mentally incapable of acting on his own)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Relationship
*
Sex
*
Please Select
Male
Female
Split %
*
Percentage of Payout Beneficiary should receive
Nominated Beneficiary
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Relationship
Sex
Please Select
Male
Female
Nominated Beneficiary
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Relationship
Sex
Please Select
Male
Female
Split %
Percentage of Payout Beneficiary should receive
Split %
Percentage of Payout Beneficiary should receive
Nominated Beneficiary
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Relationship
Sex
Please Select
Male
Female
Split %
Percentage of Payout Beneficiary should receive
Nominated Beneficiary
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date
-
Day
-
Month
Year
Date
Relationship
Sex
Please Select
Male
Female
Split %
Percentage of Payout Beneficiary should receive
PART H
Signed at (Location)
Today's Date
Example: 1-31
Day of
Example: Sunday-Saturday
Year (Last 2 digits)
Example 24
Applicant Name
First Name
Last Name
Date
/
Day
/
Month
Year
Date
Submit
Should be Empty: