Colina

Personal Details
Request Details
Declaration of Bahamian/ Foreign Status
Summary

01 Personal Details

The information given will be used to contact you to confirm your request and update you on its status.

First Name *

Last Name *

Maiden Name

Middle Name

Mobile Number *

Alternate Phone Number

E-mail *

02 Request Details

Request Type *

Use this option to obtain a loan secured by your policy’s cash value.

Use this option to withdraw dividends on deposit credited to the policy.

Use this option to obtain funds from your Universal Life policy or Premium Deposit Account.

Use this option to obtain a refund of excess funds on your policy.

Policy Number *

Requested Amount *

Proof of Identity - Please upload a copy of your valid ID: Driver's License, Passport or Voters Card. *

I hereby request a policy loan, subject to the loan provisions of the policy. If the amount requested is not available, the maximum amount available should be provided to me. I authorize Colina to apply the $20.00 fee for this transaction as an incremental loan against this policy.

I hereby request to withdraw the funds from this policy’s dividends on deposits. If the amount requested is not available, the maximum amount available should be provided to me.

I hereby request to encash/withdraw the funds from this policy. If the amount requested is not available, the maximum amount available should be provided to me.

I hereby request to have a refund from the excess funds on this policy. If the amount listed is not available, the maximum amount available should be provided to me.

I Accept.

03 Declaration of Bahamian/ Foreign Status

The following questions are required by the Foreign Account Tax Compliance Act (FATCA). Please see below for further details.

Do you have any nationality other than Bahamian or Turks Islander? *

Yes

Do you hold passports from a country other than The Bahamas or The Turks & Caicos Island? *

Yes

Are you a permanent resident of any country other than The Bahamas or The Turks & Caicos? *

Yes

Do you have a foreign telephone number? *

Yes

Do you have a foreign residence address? *

Yes

Have you been in the US for 31 days or more this calendar year or for 183 days in the past three years? *

Yes

The Foreign Account Tax Compliance Act (FATCA) is a United States of America law requring Foreign Financial Institutions (FFIs), and Non-Financial Foreign entities (NFFE) to identify U.S account holders, as well as any en- tities that are under American control. In order to facilitate the reporting requirements,The Government of The Bahamas requires financial entities, including insurance companies, to provide details on any “yes” responses.

For more information, visit: http://www.taxreporting.finance.gov.bs/fatca/

04 Summary

Thank you for your request. A Colina representative will contact you within 1 business day regarding this request. Please ensure that you have your policy number and/or the reference number readily available.

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