Royal Skandia. Financial adviser number Name of financial adviser. Company name. Address. Telephone number. Fax number.

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1 startin or addin to your Royal Skandia Bond Royal Skandia Bond number (If reserved or if adding to an existing bond) Financial adviser details Financial adviser number Name of financial adviser Company name Address Fax number address Royal Skandia only accepts business introduced by companies which have Terms of Business with us. for the trustee of The Centaurus Retirement Benefit Scheme (Malta) ( ) The Calpe Retirement Benefit Scheme (Gibraltar) ( ) December 2012 Please tick appropriate trust This document was last reviewed in December Please confirm with your financial adviser that this is the most up-to-date document for your product or servicing needs. We only sell our products through financial advisers as we believe it is important you receive independent financial advice. As it is you who chooses your financial adviser, you need to bear in mind that they are acting on your behalf and not on behalf of Royal Skandia Life Assurance Limited. You are responsible for their actions or omissions. Please sign and return your completed form to our administration centre at Skandia House, King Edward Road, Onchan, Isle of Man, IM99 1NU. All references to Royal Skandia, we, us and our in this application form mean Royal Skandia Life Assurance Limited. Important information This application form must not be used for Singapore business. Completing the form To complete this form: use CAPITAL LETTERS only use blue or black ink specify choices as appropriate do not use correction fluid; any amendments should be crossed out and initialled by authorised signatories of the corporate trustee. Please ensure that you complete all relevant sections. We will contact you regarding any missing information which will need to be provided to us in writing, and this may delay your application. A Type of application New Investment THE TYPE OF BOND CANNOT BE CHANGED AFTER IT HAS BEEN SET UP. Please select one product from the selection below. (3) Capital Redemption Bonds Life assurance Bonds Executive Redemption Bond (Terms ref ERB4) Executive Investment Bond (Terms ref EIB3) Collective Redemption Bond (Terms ref CRB4) Collective Investment Bond (Terms ref CIB3) Additional Transfer If this is an application for an additional transfer please provide your existing bond number: We have used the term Bond to refer to your chosen Royal Skandia product throughout this application. 1 of 9

2 B Details of the trust Jurisdiction: The trust name is: The trust was created on: Trust details: Please explain the reason for the establishment of the trust, what type of trust it is and detail the source/origin of the trust assets. MALTA ( ) The Centaurus Retirement Benefit Scheme QROPS provider pension transfers to the QROPS (being the evidence of origin of the assets supplied by Sovereign Pension Services Limited) GIBRALTAR ( ) The Calpe Retirement Benefit Scheme QROPS provider pension transfers to the QROPS (being the evidence of origin of the assets supplied by Sovereign Trust International Limited) C Details of the QROPS trustee applicant Corporate trustee name Sovereign Pension Services Limited Sovereign Trust International Limited Contact person of registration Registered office address (This information must be provided in full. We are unable to accept PO Boxes and care of addresses.) including area code address Stephen Griffiths Malta 4th Floor, Suite 20, Valetta Buildings South Street, Valetta VLT01 Malta maltapensions@sovereigngroup.com Jane Mills Gibraltar Suite 2B 143 Main Street Gibraltar gibraltarpensions@sovereigngroup.com Corporate website address Authorised signatories Please confirm the minimum number of authorised signatories of the corporate trustee needed to give instructions 2 D Details of the life assured This section should only be completed if you have selected the life assurance option, e.g. the Executive Investment Bond or Collective Investment Bond in section A. First life assured (Member) Second life assured (if any) Title (3) Mr Mrs Miss Mr Mrs Miss Other Other Full forename(s) Surname Address Post code Post code Sex (3) Male Female Male Female Date of birth Nationality Dual nationality 2 of 9

3 E Charges and Bond Currency Charges Please enter the reference code for your chosen charging structure which you confirm you have received and read in full: (Your financial adviser will be able to provide you with this code.) Bond currency We wish our Bond to be valued in (3) US$ Other currency (state currency) Please note if no currency is entered your Bond currency will be pound sterling ( ). THE BOND CURRENCY CANNOT BE CHANGED AFTER THE BOND IS SET UP. F Investment details Premium payment Currency (3) US$ Other currency* (state currency) Amount to be invested (anticipated total amount based upon estimated transfer value(s)) Payment method (3) 3 Electronic bank transfer Number of policies (New bonds only) Please enter the number of policies you would like: THE NUMBER OF POLICIES CANNOT BE CHANGED AFTER THE BOND IS SET UP. We normally issue 12 policy schedules per contract. 1 2 G Origin of wealth Source of funds Jurisdiction Account Name Currency Sort code SWIFT code Account number IBAN number MALTA Sovereign Pension Services Ltd ATO The Centaurus Retirement Benefit Scheme GBP RBOS GGSP GB66 RBOS GIBRALTAR Sovereign Trust International Limited ATO The Calpe Retirement Benefit Scheme GBP N/A RBOSGIGI GI49 RBOS Jurisdiction MALTA GIBRALTAR Bank name Bank address RBS International Royal Bank Place 1 Glategny Esplanade, St Peter Port Guernsey GU1 4BQ NatWest Bank PO Box 707 NatWest House 57 Line Wall Road How long has the trust held this account? Guernsey From 31 August 2012 Gibraltar From 30 August of 9

4 G Origin of wealth (continued) Full details of origin of wealth PLEASE TICK THE DESCRIPTION OPTION(S) RELATING TO THE ORIGINAL SOURCE OF THE PREMIUM FOR YOUR ACCOUNT. YOU MUST FULLY COMPLETE EACH RELEVANT SECTION RELATING TO THE DESCRIPTION OPTION(S) YOU HAVE TICKED. THIS SECTION MUST BE COMPLETED IN ALL INSTANCES (3) Description Details required Your details Transfer of pension Pension name Pension Account number Pension value Currency: Amount: Transfer date Transfer of pension Pension name Pension Account number Pension value Currency: Amount: Transfer date Transfer of pension Pension name Pension Account number Pension value Currency: Amount: Transfer date Transfer of pension Pension name Pension Account number Pension value Currency: Amount: Transfer date 4 of 9

5 H Investment choice Managing your investments Would you like someone else to manage your investments? A fund adviser - complete sections 1A and 1B below. Would you like to utilise an alternative authorised custodian? An authorised custodian - complete a 'Request to transfer to an authorised custodian account'. Please also note that if you are appointing an authorised custodian you do not need to complete the investment choice section. Section 1A. Appointment of Fund Adviser Company name Address Postcode Appointment of Fund Adviser Declaration by Sovereign Pension Services Limited and Sovereign Trust International Limited as the applicants for the Policy: We hereby appoint the Investment Manager detailed above as fund adviser for this Policy, to act on the QROPS Trustees behalf for making investment decisions in respect of the Bond. This authority is given on a discretionary manager basis. We have delegated all investment decision-making to the fund adviser. This means the fund adviser has complete discretionary authority, without consulting us, to make all investment decisions, to buy or sell assets, hold cash or other investments. We authorise Royal Skandia to act upon the investment instructions of the fund adviser. We agree that Royal Skandia is not responsible for any loss or liability to our bond arising from this appointment. We confirm that we take full responsibility for the acts or omissions of the fund adviser, including any loss in the bond as a result of their acts or omissions (including, but without limitation, failure on the part of the fund adviser to produce a reasonable investment return in relation to the bond). Further, we indemnify Royal Skandia against all claims, demands and actions against Royal Skandia relating to any such loss suffered. This includes all costs and expenses arising from or in respect of the activities and performance of the fund adviser (including, but without limitation, the cost of defending in any court of law any such claim demand or action against Royal Skandia). We agree to notify Royal Skandia in writing of any changes which affect the appointment or authority of the fund adviser and understand that Royal Skandia will continue to accept instructions from the fund adviser unless and until we advise Royal Skandia of a change in the fund adviser s appointment or authority. We understand that we can terminate the appointment of the fund adviser by giving notice in writing to both the fund adviser and Royal Skandia. Fund adviser s fee We agree to pay the fund adviser fee specified here: Payment will be based on the value at the end of the previous quarter. % a year We agree that such fees shall be payable directly to the fund adviser by Royal Skandia on receipt by Royal Skandia of this authority, which hereby authorises Royal Skandia to debit our bond with an equivalent amount which will be paid quarterly at each valuation date. Such fees will be treated as partial surrenders of the Policy/Policies. It is agreed that all assets are held in the name of Royal Skandia and all trades must be done in the name of Royal Skandia. Section 1 B. Payment details for fund adviser fees for completion by the fund adviser Preferred payment currency or Bond currency Payment method (3) Electronic bank transfer 1 BACS 2 1 Bank charges will be applicable for electronic bank transfers, for example telegraphic transfer payments. 2 BACs is only available for sterling payments to a UK bank. continued 5 of 9

6 H Investment choice (continued) Section 1 B. Payment details for fund adviser fees for completion by the fund adviser (continued) Bank account holder (name as stated on bank account) Bank account number/ IBAN* Sort code** SWIFT or BIC code** Bank name Bank address Postcode Note: payment of fund adviser fees will be approximately 6-8 weeks after the quarter end. ** IBAN stands for international bank account number and is always used in conjunction with a bank identifier code (BIC). ** A sort code is used in the UK in conjunction with a bank account number. A SWIFT code is used outside Europe in conjunction with a bank account number. A BIC code is used in Europe in conjunction with an IBAN. Investment choice Fund number or Security identifier SEDOL/ISIN (if known) Security/Fund name please enter names in full. If a Royal Skandia fund is chosen, please prefix the fund name with RS. Accumulation/ Income unit requirement Share class (if applicable, for example A, B or C) Base currency of security/ fund (eg GBP, USD) Investment % (whole % numbers only) RS GBP Deposit N/A N/A GBP 5 TOTAL: Appointment of Investment Adviser (continued) In case we need to clarify the investment choice details above, please provide us with a contact name and telephone number. Contact name including area code (daytime) Fax number including area code (evening) address HEAD OFFICE USE ONLY Bond number Net premium amount 6 of 9

7 I Declaration and application Data Privacy Notice Consent by the QROPS Trustee To: Royal Skandia Life Assurance Limited We have read and understood the Data Privacy Notice set out below and will make it available to other individuals whose Personal Data has been provided to Royal Skandia Life Assurance Limited either in this application or within accompanying documentation. Data Privacy Notice Royal Skandia Life Assurance Limited will process information ( Personal Data ) about individuals detailed in this application, included in any accompanying documentation or provided subsequently to enable the review of this application and the servicing of the subsequent Contract. The processing of Personal Data by Royal Skandia Life Assurance Limited will take place in the Isle of Man as well as in other jurisdictions as determined by Royal Skandia Life Assurance Limited. Personal Data will be processed by Royal Skandia Life Assurance Limited or released to other parties within or outside the Old Mutual Group for the following reasons Checking against credit reference or other databases to verify information provided for regulatory due diligence purposes and to prevent or detect financial crime including money laundering, terrorist financing, bribery or fraud; For the provision of services relating to reinsurance, data hosting, online services, payment or reporting of any tax or levy, or any other services Royal Skandia Life Assurance Limited provides to Policyholders from time to time; To enable an appointed Financial Adviser or Fund Adviser to assist in provision of services to the Policyholder; For the purposes of statistical analysis or market research, such information not being specific to the individual; To comply with any legal obligation which includes the releasing of Personal Data to regulators, law enforcement authorities or other bodies where Royal Skandia Life Assurance Limited is legally required to do so. Where Personal Data is released to a third party for the provision of services relating to a Contract, Royal Skandia Life Assurance Limited will ensure the Personal Data is only used for the purposes for which it is released and is subject to adequate security and protection. In some circumstances this may involve a transfer of data to a third party outside the European Economic Area (EEA). On receipt of a request to do so and on the payment of a small fee Royal Skandia Life Assurance Limited will provide a copy of an individual s Personal Data to that individual as required under the Isle of Man Data Protection Act In accordance with an individual s rights under the Isle of Man Data Protection Act 2002, Royal Skandia Life Assurance Limited will correct any inaccuracies in an individual s Personal Data held in its records. Any questions about Data Privacy should be addressed to the Data Protection Officer, Royal Skandia Life Assurance Limited, Skandia House, King Edward Road, Onchan, Isle of Man, British Isles, IM99 1NU Important information Please read the following declaration carefully. Any omission or misstatement of a material fact in this application could affect the payment of benefits under the Bond. A material fact is one which is likely to influence the assessment and acceptance of the application. If you are uncertain whether a fact is material, you should give full details so that we can assess its possible significance. If you become aware of such a fact while we are considering your application, you should notify us immediately. Declaration by the QROPS Trustee 1. We understand and agree that the contract we are applying to enter with Royal Skandia on behalf of the QROPS Trustees will be subject to Isle of Man law and that the Policy Terms and Conditions will be in the English language. 2. For the Bond we have requested in Section A, subject to the applicable Terms either: (a) If a bond number is not shown in section A of this form, we request that the amount shown in section F be invested as an initial premium for the Bond we have chosen in section A, and request Royal Skandia to issue the Bond in the name of the trust; or (b) We request that the amount shown in section F be invested as an additional premium for the Bond currently in force bearing the bond number shown in section A of this form. 3. We declare to the best of our knowledge and belief the statements made in this application, and any related documents, are true and complete and that we have not concealed any material fact. 4. We confirm that each life assured consents to this application and agrees to my acting as their QROPS Trustee for the purpose of the information provided in this application. 5. We confirm that QROPS Trustees are not incorporated in Hong Kong, Singapore or the United States of America. 6. If the QROPS Trustee becomes incorporated in the United States of America, Royal Skandia may not be able to accept any further premiums until after the QROPS trust company ceases to be incorporated in the United States of America. 7. We confirm that the investment into the Bond is within the investment powers available to the QROPS Trustees under the trust. 8. We confirm that the QROPS trust company has not been, or is not in the process of being dissolved, struck off, wound up or terminated. 9. We consent to the QROPS Trustees personal data being used in accordance with the data privacy notice. 10. We confirm that we are applying for a Royal Skandia Bond as instructed by the member. We have received a copy of the Policy Terms and Conditions relating to the chosen Bond as indicated in section A and we have had the opportunity to read it when completing this application form. 11. We may wish to invest into professional/non-retail type investment schemes, and if so, we will make sure we have had an opportunity to read the offering documents for funds of this nature. Where we decide to invest in professional/non-retail investment schemes, We accept the levels of risk associated with these, including the risk that the investment into such a scheme could result in a loss of a significant proportion, or the entire sum invested. We also confirm that we are aware of the fees payable for the chosen investment(s) to be held in our Policy. We understand that the fees exist partly to meet the promotion and distribution expenses of the product, including commission paid to a financial adviser and or fund adviser. 12. We understand that in cases where the asset(s) we have selected is not redeemable for a certain period of time, Royal Skandia may not be able to return that part of our payment until the end of that period. The description of the funds and/or assets we have chosen will give details if this applies. We may invest immediately into non-daily dealing funds with the understanding that in the event of cancellation or requiring early access that we: (a) may not get our money back immediately and payment may be delayed for some time; (b) the institution may impose penalties and therefore we may get back less than we invested, and/or (c) the only way in which to receive value may be through an in-specie transfer of that asset into the name of the trust. 13. We confirm that we have received a copy of the following items (Policy Terms and Conditions, Client Brochure). We have read and understood the items which have been explained to our satisfaction before completing this application. 14. We are aware of the charges payable on the Bond, including the charges payable in respect of the assets which may be held within it. We understand the charges exist partly to meet advice, promotion and distribution expenses. These may include initial and ongoing payments (such as commission) made by Royal Skandia to your financial adviser. These payments could be in addition to any commission payable by the asset provider to your financial adviser in respect of the assets held. Further details of the charges payable by you and the amounts payable to your financial adviser are available from your financial adviser on request. 15. We appoint the financial adviser specified in Section L of our application form to act on our behalf in accordance with the Policy Terms and Conditions. continued 7 of 9

8 I Declaration and application (continued) Please enter the country in which this application form was completed. (3) Malta Gibraltar Other (please specify) This application must be completed by the trustees unless you have asked your financial adviser to complete it. Did you complete this application form yourself (3) Yes No If No, did a third party, such as your financial adviser, complete it on your behalf? (3) Yes By signing this declaration you confirm that you have read through the declaration in sections H and I and, if a third party has completed the application form on your behalf, that all the information provided in it is correct. No QROPS Trustees Name Capacity Signature Name Date Capacity Signature Date Copies of the Policy Terms and Conditions and/or this completed application form are available from Royal Skandia on request. J Verification of customer identity The QROPS Trustees detailed in Section C currently hold acceptable applicant status which has been acknowledged by Royal Skandia. K Acceptance of appointment as a fund adviser I accept my appointment as a fund adviser as indicated in Section H 1A and will notify both Royal Skandia and the QROPS Trustee of any change to my authority. I hold the appropriate authorisation to act as a fund adviser as indicated in Section H 1A. I have attached a copy of the proof of my authorisation to be able to carry out discretionary investment management where appropriate. I have read the conditions in Section H1A & B and agree to act in accordance with them. Signature of fund adviser Full name of signatory Date address 8 of 9

9 L Financial adviser declaration THIS SECTION MUST BE COMPLETED IN ALL INSTANCES. This method of certification is required for Isle of Man regulatory purposes. Declaration by the financial adviser I declare that: I have verified the contents of the original documents where copies have been enclosed and confirm that they are true copies of the originals. I have taken reasonable steps to make sure that the funding is legitimate and in line with the member s circumstances. To the best of my knowledge and belief, all the information provided in and with this application is true and complete and was obtained from the member who is of good standing. I also confirm I will provide further information if required. I have not made any changes to the application form after the authorised signatories for the corporate trustee have signed it. I confirm that I gave advice concerning this investment to the member in on Please enter allocation rate for this Bond % Please enter fund-based commission % I confirm that, if applicable, all information provided was received directly from the member. Regulatory body authorisation number Regulator name Royal Skandia account number Full name of introducer firm Full name of financial adviser Signature of financial adviser Date Financial adviser stamp Skandia International, part of the wealth management business of Old Mutual plc, is the international group of companies which provides offshore and cross-border investment solutions. Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Royal Skandia Life Assurance Limited is registered in the Isle of Man under number 24916C. Registered and Head Office: Skandia House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0) Fax: +44 (0) Authorised and regulated by the Isle of Man Insurance & Pensions Authority. Authorised and regulated by the Financial Services Authority for business conducted in the UK. Some of the FSA s rules do not apply to non-uk based insurers. FSA register number Royal Skandia is a member of the Association of International Life Offices. When printed by Skandia this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF8721/INT /December of 9