**Form W-8IMY**

**Certificate of Foreign Intermediary, Foreign Flow-Through Entity, or Certain U.S. Branches for United States Tax Withholding and Reporting**

(Rev. June 2017)
Department of the Treasury Internal Revenue Service
OMB No. 1545-1621

**Section references are to the Internal Revenue Code.**
Go to www.irs.gov/FormW8IMY for instructions and the latest information.
Give this form to the withholding agent or payer. Do not send to the IRS.

**Do not use this form for:**
- A beneficial owner solely claiming foreign status or treaty benefits (other than a qualified intermediary (QI) acting as a qualified derivatives dealer (QDD)). Instead, use Form: W-8BEN or W-8BEN-E
- A hybrid entity claiming treaty benefits on its own behalf (other than a QI acting as a QDD). Instead, use Form: W-8BEN-E
- A foreign person claiming that income is effectively connected with the conduct of a trade or business in the United States. Instead, use Form: W-8ECI
- A disregarded entity with a single foreign owner that is the beneficial owner (other than a QI acting as a QDD) of the income to which this form relates. Instead, the single foreign owner should use: W-BBEN, W-8ECI, or W-BBEN-E
- A foreign government, international organization, foreign central bank of issue, foreign tax-exempt organization, foreign private foundation, or government of a U.S. possession claiming the applicability of section(s) 115(2), 501(c), 892, 895, or 1443(b). Instead, use Form: W-8EXP
- U.S. entity or U.S. citizen or resident. Instead, use Form: W-9
- A foreign person documenting itself for purposes of section 6050W. Instead, use Form: W-8BEN, W-8BEN-E, or W-8ECI

**Part I Identification of Entity**

1. Name of organization that is acting as intermediary: Aon Bermuda QT Holdings Ltd.
2. Country of incorporation or organization: Bermuda
3. Name of disregarded entity (if applicable), see instructions

4. Chapter 3 Status (entity type) (Must check one box only):
   - QI (including a QDD). Complete Part III.
   - Nonqualified intermediary. Complete Part IV.
   - Territory financial institution. Complete Part V.
   - U.S. branch. Complete Part VI.
   - Withholding foreign partnership. Complete Part VII.

5. Chapter 4 Status (FATCA status) (See instructions for details and complete the certification below for the entity's applicable status.)
   - Certain investment entities that do not maintain financial accounts. Complete Part XVI.
   - Owner-documented FFI. Complete Part XI.
   - Restricted distributor. Complete Part XVII.
   - Foreign central bank of issue. Complete Part XVIII.
   - Nonreporting IGA FFI. Complete Part XIX.
   - Exempt retirement plans. Complete Part XX.
   - Excepted nonfinancial group entity. Complete Part XXI.
   - Excepted nonfinancial start-up company. Complete Part XXII.
   - Excepted nonfinancial entity in liquidation or bankruptcy. Complete Part XXIII.
   - Publicly traded NFEE or NFEE affiliate of a publicly traded corporation. Complete Part XXIV.
   - Excepted territory NFEE. Complete Part XXV.
   - Active NFEE. Complete Part XXVI.
   - Passive NFEE. Complete Part XXVII.
   - Direct reporting NFEE. Complete Part XXVIII.

6. Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address (other than a registered address): Aon House, 30 Woodbourne Avenue
   City or town, state or province. Include postal code where appropriate. Pembroke, HM 08
   Country: Bermuda

7. Mailing address (if different from above)
   City or town, state or province. Include postal code where appropriate.
   Country

8. U.S. taxpayer identification number, if required ▶ 98-0242757
   QI-EIN
   WP-EIN
   WT-EIN
   EIN

9. GIIN (if applicable)

10. Reference number(s) (see instructions) Aon (Bermuda) Ltd.

For Paperwork Reduction Act Notice, see separate instructions.
Form W-8IMY (Rev. 6-2017)
JSA
6W8501 3.000