Fatca Declaration

Form ID: 10104030
Insurance FATCA/CRS Declaration
Individual declaration
US Person* or Person Residing outside India or Indian Resident
You are requested to consult a legal/tax advisor for Residential Status
Note – The information in this section is being collected because of enhancements to Kotak Mahindra Life Insurance
Company Limited‟s new policy issuance procedures in order to fully comply with Foreign Account Tax Compliance Act
(FATCA) requirements and the Common Reporting Standards (CRS) requirements pursuant to amendments made to Income-
tax Act,1961 read with Income-tax Rules, 1962.
For more information refer:
http://www.incometaxindia.gov.in/dtaa/other%20agreements/india_iga_final-_india_english.pdf
(We are unable to provide advice about your tax residency. If you have any questions about your tax residency, please
contact your tax advisor)
Below is a list of questions which could help determine your tax residency for Foreign Account Tax Compliance Act
(FATCA)/Common Reporting Standards (CRS) Declaration.
PROPOSER LIFE INSURED NOMINEE ASSIGNEE TRUSTEE

Is your Place and
Country of Birth  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No
outside India
Are you a citizen of
any other country  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No
(dual / multiple)
Are you a resident
(for tax purposes)
of any other  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No
country other than
India
Do you hold a
green card of US or
 Yes  No  Yes  No  Yes  No  Yes  No  Yes  No
any similar card for
any other country
If the answer to any of the above questions is „Yes‟, please fill the following FATCA/CRS Declaration. All the fields given below
are mandatory. Please do not leave them blank.
Parameters PROPOSER LIFE INSURED NOMINEE ASSIGNEE TRUSTEE
Client ID
Name
Father‟s name
US Person (Pls )  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No
Resident of any
other country other  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No
than US
CC\PS\FATCA declaration form\002

Country of
Residence- Please
specify the country
Taxpayer
Identification
Number (TIN)
(Mention complete
number and Submit
a copy - Mandatory)
Exemption claimed,
if any (to be
supported by
necessary
documents)
“COUNTRY OUTSIDE INDIA”
Indicia
Country issuing the
“Identity Proof”
Telephone No.
Outside India? (Pls  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No
)
If Yes, provide
Telephone no.
Citizenship Outside
India. (Pls )
If Yes, provide
country of
citizenship
Communication /
Permanent Address
Outside India? (Pls
)
If Yes, provide the
address,
Residential:
Business:
Country/ies of
Residence for Tax
purpose is outside
India? (Pls )
Power Of Attorney
(POA) of a person
outside India? (Pls
)
Source of Income
Note: Please use multiple forms in case of multiple life assured or multiple nominees

*US Person: In case of individuals, US Person means a citizen or resident of the United States. Persons who would
qualify as US Persons could be Born in the United States, Born outside the United States of a US parent, Naturalized
citizens, Green Card Holders, Tax residents. [Please note that above information is provided only for quick reference to
customers. Please consult your tax/legal advisor for details]
I / We confirm that above details provided by me / us are correct and to the best of my knowledge. I / We also confirm
that I / We will report any change in my/our tax status in future to Kotak Life Insurance (KLI) within 30 days of such
change. I acknowledge that towards compliance with tax information sharing laws, such as FATCA/CRS, KLI may be
required to seek additional personal, tax and beneficial owner information and certain certifications and
documentation from the account holder. Such information may be sought either at the time of Policy issuance or any
time subsequently.
I hereby give consent to KLI to share with any regulatory body my information such as contact details, tax
identification number / social security number, account balances / activities or any transactions undertaken with KLI.
KLI may deduct from the monies payable to me such amount as may be required to comply with any instruction issued
by a Government/ Statutory/ Regulatory authority, including, but not limited to, instructions by Indian Authorities to
comply with a foreign law, such as FATCA/CRS.
I also authorise KLI to terminate the policy in the event that appropriate documentation of Insured / Policyholder as
may be required by KLI for the compliance as aforesaid is not timely provided to KLI.
PROPOSER LIFE INSURED NOMINEE ASSIGNEE TRUSTEE
Name
Signature
Date
Kotak Mahindra Life Insurance Company Ltd. (Formerly known as Kotak Mahindra Old Mutual Life Insurance Ltd.)
Regn. No.: 107, CIN : U66030MH2000PLC128503,
Regd. Office: 2nd Floor, Plot # C-12, G-Block, BKC, Bandra (E), Mumbai-400 051, India.
Website: http://insurance.kotak.com Email:clientservicedesk@kotak.com. Toll Free No. – 1800 209 8800.

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Fatca Declaration

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Form ID: 10104030

Insurance FATCA/CRS Declaration

PROPOSER LIFE INSURED NOMINEE ASSIGNEE TRUSTEE

Parameters PROPOSER LIFE INSURED NOMINEE ASSIGNEE TRUSTEE

CC\PS\FATCA declaration form\002

CC\PS\FATCA declaration form\002

PROPOSER LIFE INSURED NOMINEE ASSIGNEE TRUSTEE

CC\PS\FATCA declaration form\002

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