WELCOME TO SAGICOR eAPPLICATION

It’s our newest innovation yet!

SAGICOR’S eAPPLICATION SOLUTION WILL ENSURE:

 “In Good Order” Submissions

 Compliant Applications and Supplemental Forms

 Improved Producer and Applicant Experience

ADDITIONAL FEATURES:

 All information that is captured in the Illustration used at time of

sale is passed to the eApplication reducing data entry.

 Information is only entered once. If the same information is

required on multiple forms the data is pre-filled.

 Electronic signature

 No need to print any forms.

 Electronic submission, no need to mail or fax the application.

S4100117
 Application for Life Insurance

Policy Number Application Number

J706099641
SECTION 1 – PROPOSED INSURED INFORMATION
Last Name First Name Middle Name Title

KHAN STEPHANIE SIRIAH Miss

Alias (If known by another name) Prior Last Name Marital Status Gender

□
X Single □ Married M X F

□ Widowed □ Divorced/Separated
Date of Birth Age Nearest Birthplace Country of Residence Status
Day Month Year X Citizen
4 2 2000 24 Trinidad and Tobago Trinidad and Tobago Resident

National Identification Number (or) Passport Number (or) Driver’s Licence Number Nationality

20000204013 92041344 Trinidad and Tobago

Issue Country Issue Country: Issue Country:
Trinidad and Tobago Trinidad and Tobago
Expiry Date: Expiry Date: Expiry Date:
MM/DD/YYYY 07/14/2025 MM/DD/YYYY MM/DD/YYYY 12/19/2033

List all countries in which you have resided in the last 5 years for a period of 6 months or more:

TRINIDAD AND TOBAGO

Contact Information Update mailing address This policy only or X All Policies
Residence Address:
Address Line 1: 10 PALM PLACE City: PENAL State:
Address Line 2: LA COSTENA GARDENS Postal Code: Country: Trinidad and Tobago
Address Line 3: PENAL ROCK ROAD Duration: 6.0
Mailing Address:
Address Line 1: 10 PALM PLACE City: PENAL State:
Address Line 2: LA COSTENA GARDENS Postal Code: Country: Trinidad and Tobago
Address Line 3: PENAL ROCK ROAD Duration: 6.0
Telephone: Home Work Mobile Email Address

868-301-0181 868-627-2684 868-301-0181 steffykhan2000@gmail.com

Preferred method of communication with Sagicor: Text □ Yes □ No or Email □X Yes □ No

Employment Information
Occupation/Profession (Full Time) State "Other" Occupation State "Prior" Occupation Employment Type Duration

Other PERSONAL BANKING OFFICER Permanent 3.0

Does the Proposed Insured’s occupation involve using any of the following: High voltage, dangerous machinery, hazardous material, corrosive chemicals,
sandblasting, working offshore, diving commercially, piloting a non-commercial airline? Yes X No

If yes, Please indicate Industry/Exact duties (If electrical, give voltage, offshore or high risk environment, and dangerous machinery.)

Business Name Telephone

SCOTIABANK TRINIDAD AND TOBAGO 868-627-2684

Page 1
CS10260EAPP – 22 November 2021

*CS10260EAPP*
 Policy Number Application Number

J706099641
Business Address: No. Street City Country Postal Code

SOUTHERN MAIN ROAD COUVA Trinidad and Tobago

Any intended changes to occupation or location? □ Yes X□ No If yes, state exact duties and where:

Student ________________________________________________ ________________________________________________

Name of Institution and Faculty Address of Institution

Occupation/Profession (Part Time or Seasonal) If none, please state “NONE”.If retired, state prior occupation. Employment Type Duration

None N/A
Does the Proposed Insured’s occupation involve using any of the following: High voltage, dangerous machinery, hazardous material, corrosive
chemicals, sandblasting, working offshore, diving commercially, piloting a non-commercial airline? □ Yes □ No
If yes, please indicate Industry/Exact duties (If electrical, give voltage, offshore or high risk environment, and dangerous machinery.)

Business Name Telephone

Business Address: No. Street City Country Postal Code

Any intended changes to occupation or location? □ Yes □ No If yes, state exact duties and where:

Student ________________________________________________ ___________________________________________________

Name of Institution and Faculty Address of Institution

SECTION 2 – APPLICANT & OWNER INFORMATION – (Complete this section if other than Proposed Insured)
Is the Applicant/Owner a corporate entity? Yes No If ‘Yes’ please complete Corporate Customer Identity Questionnaire and provide supporting
Documentation
Last Name First Name Middle Name Title

Alias (If known by another name) Prior Last Name Marital Status Gender

□ Single □ Married M F

□ Widowed □ Divorced/Separated
Date of Birth Age Nearest Birthplace Country of Residence Status
Day Month Year Citizen

Resident

National Identification Number (or) Passport Number (or) Driver’s Licence Number Nationality

Issue Country Issue Country: Issue Country:

Expiry Date: Expiry Date: Expiry Date:

MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY

List all countries in which you have resided in the last 5 years for a period of 6 months or more: ___________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

Page 2
 Policy Number Application Number

J706099641
Contact Information (at time of application) Update mailing address This policy only All Policies
Tick if Proposed Owner’s address is same as Proposed Insured
Residence Address:
Address Line 1: City: State:
Address Line 2: Postal Code: Country:
Address Line 3: Duration:
Mailing Address:
Address Line 1: City: State:
Address Line 2: Postal Code: Country:
Address Line 3: Duration:
Telephone: Home Work Mobile Email Address

Preferred method of communication with Sagicor: Text □ Yes □ No or Email □ Yes □ No

Employment Information
Occupation/Profession (Full Time) State "Other" Occupation State "Prior" Occupation Employment Type Duration

Does the Proposed Insured’s occupation involve using any of the following: High voltage, dangerous machinery, hazardous material, corrosive
chemicals, sandblasting, working offshore, diving commercially, piloting a non-commercial airline? □ Yes □ No
If yes, please indicate Industry/Exact duties (If electrical, give voltage, offshore or high risk environment, and dangerous machinery.)

Business Name Telephone

Business Address: No. Street City Country Postal Code

Any intended change in occupation or location? □ Yes □ No If ‘Yes’ state exact duties and where:

Occupation/Profession (Part Time or Seasonal) If none, please state “NONE”. (State prior occupation if retired) Employment Type Duration

Does the Proposed Owner’s occupation involve using any of the following: High voltage, dangerous machinery, hazardous material, corrosive
chemicals, sandblasting, working offshore, diving commercially, piloting a non-commercial airline? □ Yes □ No
Industry/Exact duties (If electrical, give voltage, offshore or high risk environment, and dangerous machinery. Please indicate)

Business Name Telephone

Business Address: No. Street City Country Postal Code

Any intended change in occupation or location? □ Yes □ No If ‘Yes’, state exact duties and where:

Page 3
 Policy Number Application Number

J706099641

Relationship to Insured

1. Does the Proposed Owner have one of the following relationships with the Proposed Insured: Spouse, Child, Parent, Grandchild, Grandparent,
Brother, or Sister? Yes No If Yes, Relationship: ________________________________

2. If “No” to the above question, is the Proposed Insured a legal dependant of the Proposed Owner or is the Proposed Owner the legal guardian of
the Proposed Insured? Yes No

3. If “No” to both of the above questions, does the Proposed Owner have a lawful and material economic interest in having the life of the Proposed
Insured continue? Yes No

4. Has the Proposed Owner received or been promised any incentive to participate in this transaction? Yes No

SECTION 3 – COVERAGE INFORMATION

Policy applied for: SAGICOR SAVER SERIES - ENDOWMENT
Conversion Type/Special Offer:
Application Type: New

* Please provide policy number(s) or details of special offer, as applicable

CLASSIFICATION: (Verify from Quotation)

Risk Preferred
NON SMOKER
Figures Currency
Basic Benefit/ Sum Assured
500,000.00 TT
Figures Currency
2 Benefit Sum Assured
nd

BASIC COVERAGE

Policy Applied for: SAGICOR SAVER SERIES - ENDOWMENT

Life Insurance/Coverage Duration: To age 60 Premium Paying Period: N/A

Life Protector Term: N/A Benefit Type: N/A Endowment at 65 (% Sum Assured): N/A

RIDERS AND ADDITIONAL BENEFITS

SECTION 4 – PREMIUM AND PAYMENT METHOD

508.82
Basic $_________________ Savings/Investment $___________________ 508.82
Total $_______________________

Monthly
Payment Mode:____________________ Online
Payment Method: ___________________

Lump Sum $ ________________________

508.82
Amount paid with Application $ _________________ Conditional Insurance Agreement issued? Yes X No

Page 4
 Policy Number Application Number

J706099641

SECTION 5 – BENEFICIARY DESIGNATION

Estate X Beneficiary Nominee

SECTION 6 – INSURANCE AND REPLACEMENT HISTORY

1. Does the Proposed Insured have any other life insurance or Critical Illness insurance in force? Yes X No

2. Will life or critical Illness insurance issued by Sagicor or any other company be replaced or changed as a result of
Yes X No
this application? (If ‘Yes’, please complete a Replacement Form.)

3. Does the Proposed Insured have any application (including reinstatement) for life insurance or Critical illness now
Yes X No
pending? (If ‘Yes’, please list information below.)

4. Has the Proposed Insured applied for any life insurance or Critical illness within the last twelve (12) months? (If ‘Yes’,
Yes X No
please list information below.)

5. Has the Proposed Insured applied for Insurance (including Critical Illness) exceeding TT$1,500,000
Yes X No
in the last 24 months?

Policy Issue Applied For (A), Existing

Company No. Amount Date Plan Type (E), or Replacing (R)

SECTION 7 – LAW ENFORCEMENT HISTORY Proposed

Insured
(Record details to ‘Yes’ answers in Section 7.1 below)
1. Has the Proposed Insured in the past 24 months had a Driver’s Licence revoked or suspended, or been convicted of 2
or more driving violations, or been convicted of a violation for driving while intoxicated or under the influence, or for Yes X No
driving with impaired ability because of the use of alcohol and/or drugs?

2. Is the Proposed Insured currently in a Prison or Correctional facility due to a criminal conviction? Yes X No

3. Has the Proposed Insured been charged with or convicted of a crime during the past 5 years? Yes X No

SECTION 7.1 - Details of any ‘Yes’ answers given above:

Page 5
 Policy Number Application Number

J706099641

SECTION 8 – MEDICAL HISTORY Proposed

(Record details to ‘Yes’ answers in Section 8.1 below) Insured
1. Does the Proposed Insured currently receive health care at home, or require assistance with activities of daily living such as
bathing, dressing, feeding, taking medications or use of toilet?
Yes X No

2. Is the Proposed Insured currently in a Hospital, Psychiatric, Extended or Assisted Care, Nursing facility? Yes X No

3. Has the Proposed Insured ever tested positive for the HIV virus or been diagnosed by a member of the medical profession as
Yes X No
having HIV/AIDS or the AIDS Related Complex (ARC)?

4. Has the Proposed Insured ever tested positive for or been diagnosed by a member of the medical profession as having
Yes X No
Alzheimer’s, Dementia or Cirrhosis.

5. In the past ten (10) years has the Proposed Insured had two (2) or more of the following impairments: Cancer, Diabetes,
Diabetes, Coronary artery disease (including Heart Attacks) stroke or Transient Ischemic Attack (TIA), Carotid Artery Heart
Yes X No
Valve replacement, Peripheral Vascular Disease (PVD), Peripheral Artery Disease (PAT) or had multiple strokes or TIAs.

6. Has the Proposed Insured:

a. In the past 12 months been advised by a physician to be hospitalized or to have Diagnostic Tests, Surgery, or any
Yes X No
medical procedure that has not yet been completed or for which the results are not yet available, except for tests related
to the Human Immunodeficiency Virus (AIDS)?

b. In the past 24 months been diagnosed as having or advised by a physician to have treatment for Cancer (other
than Basal Cell Carcinoma), Squamous cell carcinoma, Heart Attack, Stroke or Transient Ischemic Attack (TIA), Yes X No
Alcohol or Drug Abuse?

7. During the past 12 months have you used any form of tobacco or nicotine products including cigarettes, cigars, e-cigarettes, Yes X No
pipes, chewing tobacco, snuff, nicotine patches or gum?

8. Your current 5.3

Height ______________ (ft&& in
ft ins/cms) Weight 118
___________
lbs
lbs/kgs)
9. Have you lost more than 20 pounds in the past 12 months (other than diet or following pregnancy)? Yes X No
10. Are you currently disabled and/or receiving disability benefits? Yes X No
11. Have you ever been treated for Sickle Cell disease or trait, anemia or other blood disorder? Yes X No
12. During the past 10 years, have you consulted or been given medical advice by a member of the medical profession for:
a. Cancer (other than Basal Cell or Squamous Cell skin cancer), Malignant Tumor, Cyst, polyp or lump, Lymphoma or Yes X No
Leukemia?
b. Heart Disease including Coronary Artery Disease, Heart Attack, Heart Failure and Irregular Heartbeat, or Vascular Yes X No
Disease involving the arteries?
c. Stroke, Transient Ischemic Attack (TIA) or aneurysm? Yes X No

13. During the past 5 years, have you consulted or been given medical advice by a member of the medical profession for:
a. Parkinson’s Disease, Cerebral Palsy, Seizures, Paralysis, Multiple Sclerosis, or any Loss of Memory or Mental Capacity? Yes X No
b. Kidney Disease or Disorder? Yes X No
c. Any Lung or Breathing Disorder including Asthma, Chronic Obstructive Pulmonary Disease (COPD), Chronic Bronchitis, Yes X No
Emphysema, and Sleep Apnea?
d. Depression, Bipolar Disorder, Anxiety or any other Psychiatric Disorder? Yes X No
e. Rheumatoid Arthritis (not Osteoarthritis), Systemic Lupus (SLE), Progressive Systemic Sclerosis (PSS or Scleroderma), Yes X No
or Polymyositis?
f. Hepatitis or other Liver Disorder, Crohn’s Disease, Ulcerative Colitis, or a Disorder of the Pancreas? Yes X No
g. High Blood Pressure (Hypertension)? Yes X No
h. Diabetes, Immune System Disorder (other than related to HIV infection) or Blood Disorder? Yes X No

Page 6
 Policy Number Application Number

J706099641
14. In the past 5 years, have you used illegal drugs, consulted a member of the medical profession or been treated, hospitalized, Yes X No
or taken medication for abuse of alcohol or drugs (including prescription drugs)?
15. Does the Proposed Insured currently consume any of the following:
a. Alcohol Yes X No
Stout/Beer Wine (Glass) Liquor (# Drinks)
Daily Yes No Yes No Yes No
Weekly Yes No Yes No Yes No

b. Marijuana, Cocaine, L.S.D, Stimulants or other amphetamines? Yes X No

c. Barbiturates, Sedatives or Tranquilizers? Yes X No
d. Heroin, Morphine or other narcotic drug? Yes X No
Please complete a Drug and Substance Abuse and/or Alcohol Usage questionnaire if you answered ‘Yes’ to any of items 14 to 15d

16. Do you have tattoos? Yes X No

SECTION 8.1 – Details of any ‘Yes’ answers given above:

Page 7
 Policy Number Application Number

J706099641
SECTION 8.2 - Family History and Aviation/Avocation Questions

1. a.
Cause of Death/Current Health
Family Member Living Status Age at Diagnosis Age at Death
Mother X Yes No N/A GOOD HEALTH 46
Father X Yes No N/A GOOD HEALTH 57
Sister(s) X Yes No N/A GOOD HEALTH 19
Brother(s) Yes No X N/A

b. Did your mother, father, brother, or sister die from or were any of them diagnosed with Cancer, Heart Disease, Stroke, Yes X No
Diabetes or Kidney Disease before the age of 60 years?
2. In the past 24 months have you participated in Parachuting, Ballooning, Hang Gliding, Motorized Racing, Rock Climbing, Yes X No
Mountaineering, Rodeo, or Scuba Diving or hazardous competition or avocation of any kind? (If ‘Yes’, you will need to answer
additional questions about your activities and may be required to complete our avocation questionnaire(s).)
3. In the past 24 months have you flown, or in the next 24 months do you intend to fly as a pilot, student pilot, or crew member on Yes X No
any aircraft, other than scheduled commercial flights? (If ‘Yes’, please complete an Aviation Questionnaire)
4. Except for vacation do you intend to travel within the next 12 months? (If ‘Yes’, complete a Residence and Travel Questionnaire) Yes X No
Remarks & Special Instructions

Corrections and Amendments (Official Use Only)

Page 8
 Policy Number Application Number

J706099641
SECTION 9 - FINANCIAL INFORMATION
Please provide the following in TT
MONTHLY INCOME NET WORTH
Earned Unearned Disposable
Proposed Insured $ 10939 $0 $ 4000 115000
Owner/Applicant $ $ $
Source SALARY NONE SAVINGS VEHICLE/ SAVINGS
SECTION 10 – ANTI-MONEY LAUNDERING & COUNTER TERRORISM FINANCING
1. ‘Beneficial owner’ refers to a person on whose behalf a policy is being taken out and who will have control over dealings with the policy prior to
the insured’s death or the policy’s maturity date. The applicant and any beneficial owner for whom the applicant is acting must complete the
Customer Identity Form (Individual, Corporate or Trustee, as applicable).
Are you the intended beneficial owner of the policy applied for in this application? X Yes No

2. A Politically Exposed Person is a person entrusted with a prominent public function, or a relative or known associate of that person.
Are you a Politically Exposed Person? Yes X No

3. The following Source of Funds Declaration is required for compliance with anti-money laundering and anti-terrorism legislative requirements
and guidelines.
SALARY
Source of Funds: _________________________________________________________________________________
(Origin of money to be paid to policy)
Expected Account Activity: __________________________________________________________________________
6,105.84
(Average annual sum expected to be paid to policy)

4. I, the undersigned applicant for insurance hereby DECLARE that the currency totaling ______________
508.82 to be paid to the Insurer

by me for ________________________________
FIRST PREMIUM SALARY
has been obtained from the following source: _________________________

_____________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

SECTION 11 - FOREIGN ACCOUNTS TAX COMPLIANCE

You may be required to complete additional forms based on your answers to the following questions.

1. Are you a U.S. Citizen or the holder of a U.S. green card? Yes X No

U.S. ITIN no: (if applicable) _____________________

2. Tax residence country: Trinidad
__________________________
and Tobago

3. Counting all the days you were present in the U.S. in the current year, 1/3 of the days you were present in the preceding year and

1/6 of the days you were present in the first of these 3 years, have you been present in the U.S. for 31 days during the current year
and 183 days during the last 3 years? Yes X No

4. Are you a grantee of a power of attorney or an authorised signatory with a U.S. address? Yes X No

5. Are you giving standing instructions for the transfer of dividend income to a U.S. account? Yes X No

6. Have you designated any U.S. beneficiaries on your account? Yes X No

Page 9
 Policy Number Application Number

J706099641
SECTION 12 – DECLARATION AND CONSENT
1. How we process Personal Information
The conclusion and performance of insurance contracts is based on the collection and use of personal information. The information contained in this
application form will be used by Sagicor Life Insurance Trinidad & Tobago Limited (the “Insurer”) to process your application for insurance, to decide
whether your application for insurance coverage can be accepted and on what terms (including through underwriting where required) and for our
performance of the insurance contract with you if your application is accepted. Information we receive relating to the health or lifestyle of the
Proposed Insured will be used for underwriting purposes. This sensitive information will be held securely with access limited to those who need to
know. Information on the Proposed Insured will include information about mental and physical health; other insurance coverage; use of drugs or
alcohol; motor vehicle records; avocations; employment; prescription drug records; hazardous activities; character; general reputation; mode of living;
finances; and vocation.. If necessary, a copy of the application form and any supporting information may be provided to a reinsurer who has agreed to
share the risk associated with coverage. Your information may be shared with any licensed intermediary acting on your behalf in order to provide the
service you applied for and update records. If you do not consent to the processing of your health information, the Insurer will not be able to provide
you with any coverage that requires underwriting. You should only give your consent to the processing of sensitive personal information if you
are doing so voluntarily.

In cases where an individual is declined life insurance or offered life insurance at an increased premium based on health status, this information may
be shared with other insurers to safeguard against non-disclosure and fraudulent activity.

The Insurer has an interest in offering its clients and potential customers products that are well adjusted to their needs and will use your personal
information for market research and statistical purposes. The insurer will also analyze relevant personal information to better tune its advertising to
customer needs and develop customized product and coverage options. For greater administrative efficiency and to support business continuity the
Insurer may process your personal information using affiliated companies in the Sagicor Group and unaffiliated third-party service providers.

To help combat the funding of terrorism and money-laundering activities, the Insurer is required by law to obtain, verify and record information that
identifies each person opening a financial account. To comply with this legal requirement, we ask for your name, address, date of birth and other
information that allows us to identify you before you sign this application. We will also ask to see and will maintain copies of with Government-issued
photo identification and other documents for verification purposes. We will require you to verify and if necessary, provided updated proof of your identity
and address from time to time.

The Insurer will protect your personal information and will keep the information you have supplied confidential, except in cases where it has a legal
obligation to disclose your information to a governmental body, law enforcement agency, judicial authority or regulator.
2. Declaration
I/We, the undersigned Proposed Insured (or any parent or guardian representing a minor insured) and the Applicant, if different declare that to
the best of my/our knowledge and belief all the statements made and answers given in this application are true, complete and correctly
recorded and agree to be bound by all statements and answers made or to be made in this application (which includes any supplement to
the application). I/We acknowledge and agree that:
a. This application and any policy issued on the basis of this application shall constitute the entire contract between the Applicant and the Insurer. No
agent or other insurance intermediary may evaluate insurability, accept insurance risks, make or modify contracts or waive any of the Insurer’s
rights or requirements.
b. Except as may be otherwise provided in a Conditional Insurance Agreement made in respect of this application, insurance coverage shall not
become effective and there shall be no liability on the part of the Insurer until the entire first premium has been paid; the policy has been delivered
to and accepted by the Proposed Insured or the Applicant, if different; and all the answers in this application and any supplement hereto continue
to be complete and true answers.
c. My/our statements and answers form the basis of the insurance contract and I/We will immediately inform the Insurer in writing of any changes to
the answers given during the application process.
d. If any fraudulent or material untrue statement has been made, or material information withheld, including my/our failing to inform of any change in
country of residence or in the Proposed Insured’s health, occupation or pastimes that occurs prior to the issue of the policy applied for, this may
result in the policy being declared null and void and the policy benefits not being paid.
e. The Insurer is authorized to amend any portion of this application by making an appropriate notation of any correction or amendment in an
Amendment to the Application for Insurance and the acceptance of any policy issued by reason of this application shall constitute ratification of any
such change.
f. The Insurer will process my/our personal information whether or not this application is successful. I/We consent to the Insurer using my/our
personal information to evaluate this application for insurance and manage any related dealings with the Insurer; to provide to a reinsurer; to
administer any policy issued as a result of this application; to process any claim submitted under any such policy; and to share with another
insurance company to which I am/we are applying or in the future may apply for insurance. I/We also consent to the Insurer transferring my/our
personal information to other countries to enable the provision of in-group administrative support for insurance administration and the secure
storage of information for business continuity purposes. I/We understand that the Insurer will also process my/our personal information for the
purpose of market research and statistical analysis; deterrence of insurance fraud; for customer profiling and relationship management in support
of insurance conservation, product customization, better customer engagement; and for the making of discretionary offers to clients on a goodwill
basis.

3. Consent to Provision of Health Information

The Insurer will rely on the information provided in this application and where the policy applied for is underwritten, will rely on information provided
about the Proposed Insured’s health and lifestyle. The Insurer may require that it be supplied with health information held by persons and entities that
have any record or knowledge of the Proposed Insured’s health (“Health Information”), which may include information resulting from medical
examination of the Proposed Insured at the Insurer’s request. Your consent is needed to obtain Health Information. You do not have to give your
permission but, where you do not, the Insurer will not be able to proceed with this application unless the coverage you have applied for has no
underwriting requirement. Review of Health Information will result in the Insurer setting premiums at the rates that correspond to your disclosed health
status or declining to provide insurance. Health Information may include details of the following:

Page 10
 Policy Number Application Number

J706099641
• Your current state of health, any care, medication or treatment you are currently receiving and the results of referrals or tests you are waiting for.
• Your past health including details of any relevant illness, trauma, or referral for specialist advice or treatment, hospital admissions, consultations
with any doctor, therapist or counsellor, including whether you have a history of any disorder of the joints or muscles; malignancy, degenerative
(gradually worsening) diseases, heart disease, diabetes, depression, any mental disorder, drug or alcohol misuse or tobacco use.
• Details of any blood pressure readings, blood tests, biopsies, electrocardiograms (heart tests), height and weight, urinalyses (tests on urine),
x-rays or other investigations.
• History of certain diseases among your immediate family.

I, the undersigned Proposed Insured (or the parent or guardian representing a minor Proposed Insured) authorize persons and entities that have records
or knowledge of my health to provide such information to the Insurer; its employees; authorized representatives; reinsurers and any person or
organization engaged by the Insurer to perform administrative, legal or other professional services in connection with the Insurer’s business; consent to
automated decision-making where electronic underwriting applies to the level of coverage applied for; and agree to undergo electrocardiogram, x-ray,
blood tests (for diabetes, AIDS, etc.) or any other tests considered necessary by the Insurer and/or its reinsurers. A copy of this consent shall be as valid
as the original.

Proposed Insured (or parent/guardian of minor) X Yes, I consent No, I do not consent

4. Authorization of E-business
The undersigned Applicant hereby authorizes the conduct of business with the Insurer by electronic means, including business in respect of existing
policies of the Applicant issued or assumed by the Insurer. The Applicant may in preference to conducting business in-person elect to transact such
of the following by electronic means as are permitted by law and enabled by the Insurer: electronic completion, signature and submission of the
insurance application; electronic payment remittance; and electronic delivery of any policy or other document issued in consequence of this
application. The Applicant further agrees that:
a. if the Insurer accepts an application submitted by electronic means and delivers a policy in electronic form, any request for the reproduction on paper
of such application or policy or of any other record maintained by the Insurer in respect of that policy may be subject to the payment to the Insurer of a
reasonable administrative fee reflecting the costs associated with reproduction on paper.
b. the Insurer is authorized to receive and act on instructions given remotely by electronic means (“Instructions”) in respect of policies owned by the
Applicant where the Insurer reasonably believes those Instructions to have been given by the Applicant. The Insurer shall have the right to require
certain types of policy transactions to be effected in person and to restrict the amount of policy proceeds loaned or paid out on the basis of Instructions
to such monetary limit as the Insurer, in its sole discretion, shall have determined from time to time for online transactions of that type.
c. in order to access a policy or any related record issued by the Insurer in electronic format, a personal computing device with installed software
capable of reading Portable Document Format (pdf) files will be required and confirms the Applicant has and will have access to a device with the
stated capacity.
5. Grounds for immediate termination
The undersigned Applicant agrees that the Insurer shall be entitled to immediately terminate a policy issued as a result of this application without notice:
a. if any act or omission by the Applicant would result in the breach by the Insurer of any applicable law, inter-governmental agreement, reporting
standard, regulation or guideline (as amended, consolidated, extended or re-enacted from time to time), including without limitation those governing
anti-money laundering, the countering of terrorism financing and the exchange of tax-related information.
b. if the Insurer has issued an underwritten policy as a result of this application and the consent given in this application to access Health Information
(which is relevant to the discovery of material non-disclosure) is withdrawn.

6. Direct Marketing
We would like provide you with marketing information about the products and services of the Insurer and of affiliated companies in the Sagicor Group
that may be of interest to you. Please indicate whether you would like to be contacted for this purpose by checking the appropriate box below.

I/We consent to receiving direct marketing by the Insurer and its affiliates concerning products and services that may be of interest. I/We consent to
the sharing of my/our contact information within the Sagicor Group and agree that the Insurer and its affiliates may contact me/us for marketing
purposes by post, text message, telephone, e-mail and any other appropriate mode of communication..

Proposed Insured (age 18 or older) X Yes No

Applicant (if different from Proposed Insured) Yes No

By signing this application, you are confirming that you have read and understood all of the information on this form.

PORT OF SPAIN Trinidad and Tobago

Dated at ............................................................................................................................................................................................ (state place in territory))

17
this...................................day
JULY
of ………….....……..……………..………20 ..….......….…
2024

………………………..………….…………………….……………………... ............................................................................................
Signature of Proposed Insured Signature and Title of Applicant, if different
(or parent or guardian representing a minor) (State title if signing as authorized representative of corporate applicant)

RASHIDA WOLFE
..................................................................................................... ..............................................................................
Signature of Producer (if present as witness when application is signed) Name of Producer

Page 11
 Policy Number Application Number
J706099641
PRODUCER’S REPORT
A. How long have you known the Proposed Insured? ________
0 years _________
2 months

B. Are you related to the Proposed Insured? Yes X No Relationship _______________________

C. Are you aware of any information concerning health, character, reputation, living environment, bankruptcy, questionable
associates, financial difficulties, etc of the Proposed Insured(s)? Yes X No (If ‘Yes’, please give details)
_______________________________________________________________________________________________
D. Did you personally interview the Proposed Insured(s)? X Yes No (If ‘No’, please give details)
_______________________________________________________________________________________________
E. Is the Application Form being signed by the Proposed Insured(s) in your presence? Yes X No (If 'No', Witness
Signature not required)

F. If third party, did you see the Proposed Insured(s) at time of completion of this application? Yes No X N/A
(If ‘No’, state why)_________________________________________________________________________________

G. Was any other person(s) present to answer questions? Yes X No (If ‘Yes’, please give details)

_______________________________________________________________________________________________

H Is the Proposed Insured blind or unable to read and/or write? Yes X No (If ‘Yes’, Attestation Form to be completed).

I. Are you splitting this case? Yes X No If ‘Yes’, please complete the following:

Advisor(s) Advisor(s) Number Agency % Split

1. ________________________
RASHIDA WOLFE ______________________
65894 Marc Aanensan
_________________________ ___________
100

2. ________________________ ______________________ _________________________ ___________

J. 1. Is valid Photo ID attached? X Yes No 2. Is valid proof of address attached? X Yes No
3. Is valid proof of income attached? X Yes No
Purpose of Insurance: __________________________________________________________________________________
RETIREMENT INCOME

KINDLY ISSUE ON 28TH

Additional remarks: ____________________________________________________________________________________

Producer’s Certification
I certify that I have reviewed the appropriate documentation and have truly and accurately recorded the information supplied by the
Proposed Owner and Proposed Insured; that I know of no condition affecting the insurability of the applicant not fully disclosed in the
application; and that I have made no declaration, representation or waiver regarding insurance coverage or the terms of this
application. I further certify that I have fully complied with all the applicable policies and procedures of the Insurer, including its
replacement rules where applicable. I assume responsibility for submission of the first premium and for ensuring timely delivery of
any policy issued as a result of this application.

RASHIDA WOLFE
Producer’s Name/Number (Please Print)

65894 07/17/2024
Producer’s Signature SAGICOR FINANCIAL CENTRE Date
PORT OF SPAIN
Trinidad and Tobago
Signature of Producer’s Manager Date

Page 12
 PERSONAL PHYSICIAN INFORMATION

1. Do you have a personal Physician? X Yes No

PENAL MEDICAL ASSOCIATES
Name of your personal Physician
CLARKE ROAD JUNCTION, PENAL
Address of your personal Physician
05/01/2024
Date of last visit
Other B 12 SHOT
Reason for last visit

Diagnosis/Results NONE/ GOOD HEALTH

NONE
Treatment/Medication Prescribed

2. If no personal Physician

Name of last Physician, clinic, laboratory or hospital visited

Address of Physician, clinic, laboratory or hospital visited

Date of last visit

Reason for last visit

Diagnosis/Results

Treatment/Medication Prescribed
1a. Is your mother still alive? X Yes No

Did your mother die or was diagnosed with Cancer, Heart Disease, Stroke,
Diabetes, Kidney Disease, Parkinsons, Alzheimers, Multiple Sclerosis or Motor
Neuron Disease prior to age 60? Yes X No

Unknown (including adoption)? Yes X No

Other? Yes X No

Please provide details

1b. Is your father still alive? X Yes No

Did your father die or was diagnosed with Cancer, Heart Disease, Stroke,
Diabetes, Kidney Disease, Parkinsons, Alzheimers, Multiple Sclerosis or Motor
Neuron Disease prior to age 60? Yes X No

Unknown (including adoption)? Yes X No

Other? Yes X No

Please provide details

1c. Is your sister still alive? X Yes No N/A

Did your sister/s die or was diagnosed with Cancer, Heart Disease, Stroke, Yes X No
Diabetes, Kidney Disease, Parkinsons, Alzheimers, Multiple Sclerosis or Motor
Neuron Disease prior to age 60?

How many sister/s died or were diagnosed as above?

1? Yes No

2 or more? Yes No

Unknown? Yes X No

Other? Yes X No

Please provide details

UW8.2.1a Page
Page11ofof12
1d. Is your brother still alive? Yes No X N/A

Did your brother/s die or was diagnosed with Cancer, Heart Disease, Stroke,
Diabetes, Kidney Disease, Parkinsons, Alzheimers, Multiple Sclerosis or Motor
Neuron Disease prior to age 60? Yes No

How many brother/s died or were diagnosed as above?

1? Yes No

2 or more? Yes No

Unknown? Yes No

Other? Yes No

Please provide details

UW8.2.1a Page 22 of
Page of 2
1
 REQUEST FOR ADDITION OF REVOCABLE BENEFICIARY

J706099641
POLICY NO: _________________________

Life Insured STEPHANIE SIRIAH

______________________________________
________________________________
First Name Middle Name
KHAN
____________________________________________________________________________________________
Last Name
Note – All the following persons must sign this form
Policyowner

STEPHANIE KHAN
I ………………………………………………...would like to add the following as beneficiary(ies)on the above
mentioned policy. Check if Beneficiary is a Company/Entity Check if Beneficiary is a Company/Entity

RAVEN
Beneficiary (1) _______________________________ Beneficiary (2) ________________________________
First Name First Name

PALLOO Mr
____________________________________________ _____________________________________________
Middle Name Last Name Title Middle Name Last Name Title

10 PALM PLACE, PENAL ROCK RD

Address: ___________________________________ Address: _____________________________________
No. Street No. Street

PENAL Trinidad and Tobago

_____________________________________________________ _______________________________________________________
City Country City Country

05 /___/___
Date of Birth:___ 05 1990 Sex: Male X
□ Female □ Date of Birth:___ /___/___ Sex: Male □ Female □
DD MM YY
YYYY DD MM YY
YYYY

868
Phone No: _(_____ 287-5309
)_______________ Phone No: _(_____ )_______________
Country Code Number Country Code Number

Trinidad and Tobago

Nationality:___________________________________ Nationality:____________________________________
Trinidad and Tobago
Country of Birth: _____________________________ Country of Birth: _______________________________
19900505034
ID#DP#PP#: _________________________________ ID#DP#PP#: ___________________________________
Fiancee
Relationship to Insured: _______________________ Relationship to Insured: _________________________

Name of Employer/Profession: __________________ Name of Employer/Profession: ___________________

Phone No: (______)_______________ Phone No: (______)_______________

Country Code Number Country Code Number

Sagicor Life Insurance Trinidad & Tobago Limited is hereby requested to make the above changes for which this shall
be good and sufficient authority.

In the case of apparent errors or omissions discovered by Sagicor Life Insurance Trinidad & Tobago Limited in
the foregoing request, Sagicor Life Insurance Trinidad & Tobago Limited is hereby authorized to correct and
complete this form and a copy of such amended form will be returned to the Policyowner. It is agreed that such
changes have been ratified if the form is not returned within thirty days after receipt thereof.

It is agreed that the original application, the policy and this request shall together form the basis of the contract.

PORT OF SPAIN Trinidad and Tobago

Dated at __________________________________ 17
this __________day JULY 2024
of __________________________20_____

____________________ ______________ ________________________ _________________________

Policyowner Signature Photo ID # Witness (Block Letters) Witness Signature
CS10152 – June 2022

*CS10152*
 REQUEST FOR REMOVAL OF REVOCABLE BENEFICIARY

POLICY NO: _________________________

Life Insured ____________________________________ ________________________________

First Name Middle Name

_______________________________________________________________________________________
Last Name
Note – All the following persons must sign this form
Policyowner

I …………………………………………would like to remove the following as beneficiary(ies) on the above mentioned

policy.

Beneficiary (1) _____________________________________ ________________________________

First Name Middle Name
____________________________________________________________________________
Last Name

I …………………………………………would like to remove the following as beneficiary(ies) on the above mentioned

policy.

Beneficiary (2) ____________________________________ ________________________________

First Name Middle Name
__________________________________________________________________________
Last Name

Sagicor Life Insurance Trinidad & Tobago Limited is hereby requested to make the above changes for which this shall
be good and sufficient authority.

In the case of apparent errors or omissions discovered by Sagicor Life Insurance Trinidad & Tobago Limited in
the foregoing request, Sagicor Life Insurance Trinidad & Tobago Limited is hereby authorized to correct and
complete this form and a copy of such amended form will be returned to the Policyowner. It is agreed that such
changes have been ratified if the form is not returned within thirty days after receipt thereof.

It is agreed that the original application, the policy and this request shall together form the basis of the contract.

Dated at __________________________________ this __________day of __________________________20_____

______________________ ___________ ______________________ _________________________

Policyowner Signature Photo ID # Witness (Block Letters) Witness Signature

CS10152 – June 2022

STEPHANIE SIRIAH KHAN

10 PALM PLACE LA COSTENA GARDENS PENAL ROCK ROAD

PENAL Trinidad and Tobago

10 PALM PLACE LA COSTENA GARDENS PENAL ROCK ROAD

PENAL Trinidad and Tobago

868-301-0181 868-627-2684 868-301-0181

steffykhan2000@gmail.com

Trinidad and Tobago

Trinidad and Tobago

1000373522

02/04/2000 SAN FERNANDO Trinidad and Tobago

X
 X
X

07/17/2024
 RASHIDA WOLFE
11th JULY 2024
 Page 1 of 5

Your SAVINGS STAFF ACCOUNT Account Summary

SAN FERNANDO 62-SCOTIA (627-2684)
49 HIGH STREET
SAN FERNANDO
www.scotiabank.com/tt

STEPHANIE KHAN
10 PALM PLACE LA COSTENA GARDENS
PENAL ROCK ROAD PENAL
Account Number: 2413036
PENAL
TRINIDAD AND TOBAGO Transit Number: 60285

Statement Period: 15APR24 to 15MAY24

2413036 - SAVINGS STAFF ACCOUNT - TTD

Account Summary

No. of Deposits 11 Service Charges TT$ 5.25

Deposits TT$ 13,003.59 Record Keeping Fees TT$ 0.00
No. of Withdrawals 38 Total Interest Paid TT$ 0.00
Withdrawals TT$ 14,140.06 Interest Rate 0.00%
Enclosures 0

*Trademark of The Bank of Nova Scotia, used under license.

 Page 2 of 5

Your SAVINGS STAFF ACCOUNT Account Summary

STEPHANIE KHAN 62-SCOTIA (627-2684)
2413036
www.scotiabank.com/tt

Transactions ( Withdrawals & Deposits ) - 2413036

Transaction Description Amount Balance
Date
CREDIT DEBIT
OPENING BALANCE TT$ 1,210.99
17APR POS DEBIT TT$ 60.00 -
STARBUCKS COUVA, 0179065

17APR THIRD PARTY TRF BNS TT$ 400.00 - TT$ 750.99

Transfer to RAVEN PALLOO 6676

19APR POS DEBIT TT$ 25.00 -

STARBUCKS COUVA, 0608479

19APR POS DEBIT TT$ 77.00 - TT$ 648.99

DEBE CHINESE PENAL TT

22APR POS DEBIT TT$ 123.97 -

DROP CARIBBEAN LTD PORT OF SPAINTT

22APR FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 473.00 - TT$ 52.02

Transfer to STEPHANIE KHAN 9663

25APR IB TRANSFER CR TT$ 300.00 +

Transfer from STEPHANIE KHAN 9663

25APR THIRD PARTY TRANSFER TT$ 200.00 +

Transfer from RAVEN PALLOO 6676

25APR ABM WITHDRAWAL TT$ 340.00 -

*4 PENAL JUNCTION PENAL TT 0224296
4303950280151400
25APR POS DEBIT TT$ 147.00 - TT$ 65.02
DEBE CHINESE PENAL TT

26APR SCOTIA DIRECT CREDIT TT$ 4,106.42 +

010100020001113, SCOTIA BANK CENT SALARY

26APR FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 300.00 -

Transfer to STEPHANIE KHAN 9663

26APR FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 1,329.89 -

Transfer to STEPHANIE 9762

26APR THIRD PARTY TRANSFER TT$ 670.00 +

Transfer from RAVEN PALLOO 6676

26APR ABM WITHDRAWAL TT$ 1,000.00 -

*SOUTHERN MAIN RD. COUVA TT 0551441
4303950280151400
26APR FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 337.50 - TT$ 1,874.05
Transfer to STEPHANIE 9762

29APR STANDING ORDER TT$ 30.00 -

30395 2409495-SCOTIA COUVA STAFF ACCOUNT

29APR POS DEBIT TT$ 110.00 -

ENDECON DESIGNS & CONS SIPARIA, 053941

29APR THIRD PARTY TRF BNS TT$ 640.00 -

Transfer to RAVEN PALLOO 6676

29APR THIRD PARTY TRANSFER TT$ 200.00 +

Transfer from RAVEN PALLOO 6676

29APR THIRD PARTY TRF BNS TT$ 200.00 -

Transfer to NIRVANA GAJADHAR 6732

*Trademark of The Bank of Nova Scotia, used under license.

 Page 3 of 5

Your SAVINGS STAFF ACCOUNT Account Summary

STEPHANIE KHAN 62-SCOTIA (627-2684)
2413036
www.scotiabank.com/tt
Transactions ( Withdrawals & Deposits ) - 2413036
Transaction Description Amount Balance
Date
CREDIT DEBIT
29APR ABM WITHDRAWAL TT$ 500.00 -
RBL UNIPET BARRACKPORE TT 0091422
4303950280151400
29APR SERVICE CHARGE TT$ 4.00 - TT$ 590.05
RBL UNIPET BARRACKPORE TT For 29APR24

30APR POS DEBIT TT$ 62.00 -

STARBUCKS COUVA, 0160278

30APR POS DEBIT TT$ 20.95 - TT$ 507.10

R.S. SUPERCEN BARRACKPORE TT

01MAY FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 200.00 - TT$ 307.10

Transfer to STEPHANIE KHAN 9663

03MAY BRANCH WITHDRAWAL TT$ 180.00 -

COUVA

03MAY IB TRANSFER CR TT$ 500.00 + TT$ 627.10

Transfer from STEPHANIE KHAN 9663

06MAY POS DEBIT TT$ 123.97 -

DROP CARIBBEAN LTD PORT OF SPAINTT

06MAY POS DEBIT TT$ 82.95 - TT$ 420.18

Anand Low Price Penal, 0736257

07MAY ABM WITHDRAWAL TT$ 200.00 - TT$ 220.18

*BNS SOUTHERN MAIN ROAD COUVA TT 0109709
4303950280151400
08MAY POS DEBIT TT$ 150.00 - TT$ 70.18
SAVE BETTER SUPERMARKE LA BREA TT

09MAY IB TRANSFER CR TT$ 300.00 +

Transfer from STEPHANIE KHAN 9663

09MAY THIRD PARTY TRF BNS TT$ 300.00 - TT$ 70.18

Transfer to RAVEN PALLOO 6676

10MAY SCOTIA DIRECT CREDIT TT$ 4,724.67 +

010100020001112, SCOTIA BANK CENT SALARY

10MAY FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 800.00 -

Transfer to STEPHANIE KHAN 9663

10MAY FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 403.53 -

Transfer to STEPHANIE 9762

10MAY FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 1,000.00 -

Transfer to STEPHANIE KHAN 9663

10MAY MOBILE OB TRF DR TT$ 600.00 -

TRF TO: STEPHANIE KHAN REPUBLIC BANK 010100903
500035507701
10MAY SPECIAL SERVICE CHARGE TT$ 1.25 -
Third Party TRF Fee, T6617194 For 10MAY24

10MAY THIRD PARTY TRANSFER TT$ 2,000.00 +

Transfer from RAVEN PALLOO 6676

10MAY FUNDS TRANSFER ACCOUNT/PAYMENT TT$ 2,000.00 -

Transfer to STEPHANIE KHAN 9663

10MAY CREDIT MEMO TT$ 1.25 +

Third Party TRF Fee - Rev

10MAY CREDIT MEMO TT$ 1.25 +

Third Party TRF Fee - Rev

*Trademark of The Bank of Nova Scotia, used under license.

 Page 4 of 5

Your SAVINGS STAFF ACCOUNT Account Summary

STEPHANIE KHAN 62-SCOTIA (627-2684)
2413036
www.scotiabank.com/tt
Transactions ( Withdrawals & Deposits ) - 2413036
Transaction Description Amount Balance
Date
CREDIT DEBIT
10MAY ABM WITHDRAWAL TT$ 1,000.00 -
*BNS SOUTHERN MAIN ROAD COUVA TT 0110306
4303950280151400
10MAY POS DEBIT TT$ 248.05 - TT$ 744.52
ANAND LOW PRICE SUPERM DEBE, 0674960

13MAY THIRD PARTY TRF BNS TT$ 500.00 - TT$ 244.52

Transfer to RAVEN PALLOO 6676

14MAY POS DEBIT TT$ 70.00 - TT$ 174.52

LINDAS BAKERY COUVA TT

15MAY ABM WITHDRAWAL TT$ 100.00 - TT$ 74.52

*BNS SOUTHERN MAIN ROAD COUVA TT 0110663
4303950280151400

CLOSING BALANCE TT$ 74.52

*Trademark of The Bank of Nova Scotia, used under license.

 Page 5 of 5

Your SAVINGS STAFF ACCOUNT Account Summary

STEPHANIE KHAN 62-SCOTIA (627-2684)
2413036
www.scotiabank.com/tt

*Trademark of The Bank of Nova Scotia, used under license.