FATCA (US Foreign Account Tax Compliance Act) Declaration

Foreign Account Tax Compliance Act (FATCA) is a United States of America (US) law, which affects Financial Institutions worldwide, aims at reducing tax evasion by US persons. FATCA requires Financial Institutions outside the US to provide information regarding their customers who are US persons to the US Inland Revenue Service (US IRS). In compliance with the above, Great Eastern Life Assurance (Malaysia) Berhad (the "Company") is required to obtain information pertaining to the tax residency of each account holder pursuant to FATCA.

FATCA (US Foreign Account Tax Compliance Act) Declaration

I/We agree that I/we will update the Company promptly of any change or addition to the information provided herein about me/us, the life assured, the beneficiary named in this proposal or of the policy and any other relevant persons (if any, and collectively with the life assured and the beneficiary the "Relevant Persons") as the Company may reasonably require.

I/We further agree, and represent to the Company that each Relevant Person has agreed when information about him is provided to the Company, that the Company may disclose such information for the purpose of its compliance with any applicable rules, laws and regulations, codes of practice or guidelines or to assist in law enforcement and investigations by relevant authorities.

I/We understand that the Company will not be liable for any costs or losses that may be incurred to me/us or any of the Relevant Persons due to actions of the Company permitted herein. In this connection, I/we agree to indemnify the Company against all claims of the Relevant Persons for the aforesaid costs or losses.

I/We further understand that my/our failure to fulfill any of the obligations herein, or any of untrue or inaccurate representations given herein, will entitle the Company to deduct or withhold such amount from any payment payable under the relevant policy, and/or to terminate the policy without being held liable, to the extent permitted by law, and I/we will indemnify the Company against all costs and losses that may be incurred to it theref reasonably required by the Company to evaluate my/our proposal and to provide the products or services which I am/we are applying for.