SAGICOR ADVISOR’S REPORT OF HOME VISIT

Application/Policy Number

PLEASE PRINT

1. Applicant’s Title Surname First Name Middle Initial(s)

2. Full Home Address of Applicant

3. Mailing Address of Applicant

4. Confirmation of Client that the following evidence is not available. Please confirm those that are not applicable by
ticking the box.
• Fixed Utility Bill
• Bank Statement
• Credit Union Statement
• Statement from other regulated financial entity, e.g. Gobe Finance Inc, Signia Financial, etc
• Statement from Hire Purchase or Financing Company, e.g Massy Homes, Standards
• Bill or other Statement from a Government Agency
• Third Party Confirmation from an Approved Person
• Third Party Confirmation from an Adult with whom the client lives
• Tenancy Agreement
• Any other Standard Form of Address Verification Material
• Insurance Company Renewal Notice (excluding Sagicor Life Inc.)

I ____________________________________ hereby certify that none of the options in section 4 are available to me
to assist in confirming my residential address.

I hereby certify that to the best of my knowledge, all the statement and answers above are true.

Name of Customer: _________________________________ Signature: _________________________

Date: ___________________________

CS10212 - February 2021 - T'dad only

*CS10212*
 SAGICOR ADVISOR’S REPORT OF HOME VISIT

Application/Policy Number

5. Date of Visit to Applicant 6 Did the visit take place at the address listed above?
Yes No
DD MM YY

7. Do you have reasonable grounds to believe that the Applicant resides at the address listed above?

Yes No

8. Reason for Home Visit

I hereby certify that to the best of my knowledge, all the statement and answers above are true.

Name of Advisor: _________________________________ Signature: ___________________________

Date: ___________________________

FOR OFFICIAL USE ONLY (TO BE COMPLETED BY THE BRANCH MANAGER/AGENCY)

PRINT NAME: ____________________________ SIGNATURE: ________________________