Identification form Associations Zurich account / policy number (if known) This Form must be completed together with your Zurich application or request form and mailed to:, Locked Bag 994, North Sydney NSW 2059 1 Association details Full name of Association Full name of the following officers (or equivalent in each case) Title Full Given Name(s) of officer Surname Chairman Secretary Treasurer Association type (select 4 only ONE of the following categories) Unincorporated Association Go to Section 2 Incorporated Association Go to Section 3. You do not need to complete Section 2 2 Unincorporated association Address of principal place of administration (PO Box is NOT acceptable) Go to Section 4. You do not need to complete Section 3 ZU10413 - STJA-002146-2008 Zurich Australia Limited ABN 92 000 010 195 AFSL 232510 Zurich Investment Management Limited ABN 56 063 278 400 AFSL 232511 Locked Bag 994 North Sydney NSW 2059 Telephone: 131 551 Facsimile: 02 9995 3797 www.zurich.com.au Identification Form for Associations 1 of 5
3 Incorporated association Unique identification number issued upon incorporation (eg. ACN) The body responsible for incorporating the Association (select 4 only ONE of the following categories) State body Territory body Overseas body Select 4 only ONE of the following categories and provide the information requested Address of principal place of administration (PO Box is NOT acceptable) Address of registered office (PO Box is NOT acceptable) Name and residential address of the public officer (or president, secretary or treasurer if there is no public officer) Title Full Given Name(s) of officer Surname Position Address (PO Box is NOT acceptable) Go to Section 4 4 What identification items do we need from you? In accordance to the AML/CTF Law, we must verify the identity of customers before processing your application or request. Please provide a certified copy of ONE of the following documents: The Constitution or Rules of the association; The minutes of an association meeting; In the case of an Incorporated Association - information provided by ASIC or the State, Territory or overseas body responsible for the incorporation of the association. Documents that are written in a language that is not English, must be accompanied by an English translation prepared by an accredited translator. If you cannot provide any of these documents or you are unsure how to complete your identification form, please contact us on 131 551 for assistance. Identification Form for Associations 2 of 5
5 Identifying a member For Unincorporated Association in addition to providing the Association details and proof of identity, you must also provide details of the member who is signing on behalf of the Association by completing the Identification form for Individuals on page 4 and 5. For Incorporated Association please make sure you read the Privacy Statement and sign the Declaration below. Your privacy Zurich is bound by the National Privacy Principles. In completing this form or questions herein you will be providing us with your personal and, perhaps, sensitive information. The collection and management of this information is governed by the Privacy Act 1988. For a more detailed explanation of Zurich s Privacy Policy please visit our website at www.zurich.com.au or contact the Zurich Privacy Officer on 132 687 or email us at Privacy.Officer@Zurich.com.au. Declaration I declare that the information and any documents I have provided are true and correct. Signature Date / / Signatory s full name Identification Form for Associations 3 of 5
Identification form Associations Individuals 6 Personal details Title Surname Full Given Name(s) Date of birth / / Residential address (PO Boxes not allowed) Full name of Association Your privacy Zurich is bound by the National Privacy Principles. In completing this form or questions herein you will be providing us with your personal and, perhaps, sensitive information. The collection and management of this information is governed by the Privacy Act 1988. For a more detailed explanation of Zurich s Privacy Policy please visit our website at www.zurich.com.au or contact the Zurich Privacy Officer on 132 687 or email us at Privacy.Officer@Zurich.com.au. Declaration I declare that the information and any documents I have provided are true and correct. Signature Date / / Signatory s full name There may be instances where we are required to collect further information. Where this is the case we will contact you. Zurich Australia Limited ABN 92 000 010 195 AFSL 232510 Zurich Investment Management Limited ABN 56 063 278 400 AFSL 232511 Locked Bag 994 North Sydney NSW 2059 Telephone: 131 551 Facsimile: 02 9995 3797 www.zurich.com.au Identification Form for Associations 4 of 5
7 What identification items do we need from you? Please tick which one applies You need to attach a certified copy (see below) of ONE of the following photographic documents: An Australian passport (provide the pages that identify you, including the page with your photograph). A passport that has expired up to 2 years ago is also acceptable; An Australian State or Territory driver s licence bearing your photograph (front and back copies are required); A proof of age card issued by an Australian State or Territory (must contain a photograph of you); A Foreign passport containing your photograph and signature (see below for information on providing foreign language documents). OR If you cannot provide a certified copy of one of the above documents then you must provide certified copies of one document from column A and one document from column B. A B Australian birth certificate OR Australian death certificate (for death claims only) Letter from Centrelink (or other Commonwealth, State or Territory agency) issued to you within the last 12 months regarding a government assistance payment showing your name and residential address Australian citizenship certificate Utilities bill or local government notice issued to you within the last three months showing your name and residential address Health card issued by Centrelink Notice issued by the ATO to you within the last 12 months showing your name and residential address Pension card issued by Centrelink (front and back copies) Notice from school principal showing name, residential address and period of attendance of person under 18 issued within previous three months If you cannot provide any of these documents or you are unsure how to complete your identification form please contact us on 131 551 for assistance. Who can certify copies of documents? A financial adviser or officer with, or authorised representative of, a holder of an Australian financial services licence, having two or more continuous years of service with one or more licensees; A lawyer who is enrolled on the roll of the Supreme Court of a State or Territory, or the High Court of Australia, as a legal practitioner (however described); An accountant who is a member of the Institute of Chartered Accountants in Australia, CPA Australia or the National Institute of Accountants with two or more years of continuous membership; An officer of a financial institution with two or more continuous years of service with one or more financial institutions (for the purposes of the Statutory Declaration Regulations 1993); A post office worker being a permanent employee of the Australian Postal Corporation with two or more years of continuous service who is employed in an office supplying postal services to the public, OR agent of the Australian Postal Corporation who is in charge of an office supplying postal services to the public; A police officer, Justice of the Peace, Magistrate or judge of a court; An Australian consular officer (within the meaning of the Consular Fees Act 1955) or an Australian diplomatic officer; A chief executive officer of a Commonwealth court; A registrar or deputy registrar of a court; A notary public (for the purposes of the Statutory Declaration Regulations 1993). How to certify a copy of a document The law requires that we receive certified copies of the identification documents you provide us. A certified copy is a document that has been certified as a true copy of an original document by certain persons. An example of a certified document: I, John Smith of 123 Park, Sydney NSW 2000 in the capacity of a Justice of the Peace certify that this copy is a true and accurate copy of the original. Signature: J. Smith Date: 1/7/2008 Please note: any identification documents that are in a foreign language must be accompanied by an English translation from an accredited translator. Identification Form for Associations 5 of 5