APPLYING FOR ACCOUNT P R A A C A E R A. Financial adviser stamp. Please enter your business postcode

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1 Financial adviser stamp Please enter your business postcode APPLYING FOR TRANsFER PAYMENTS *PPPPEN01* TO YOUR Old Mutual Wealth Professional Pension ACCOUNT Please use BLOCK CAPITALS only and blue or black ink. Please complete all relevant sections. If any are incomplete, we will write to you and ask you for the missing information, which may delay your application. All references to Old Mutual Wealth in this application mean Old Mutual Wealth Life Assurance Limited. Please note that we cannot accept: a) any transfer of benefits from a final salary scheme unless the application is made through a financial adviser who has the appropriate FCA authorisation or where the advice has been provided to that adviser by a firm who has the necessary FCA permissions. b) any transfers from unfunded final salary schemes. c) any transfer that includes funds that have been crystallised into capped or flexi-access drawdown. Those funds can be transferred to an alternative Old Mutual Wealth pension product if required. d) any block transfers that may protect tax free cash entitlements and/or a protected early retirement age. FINANCIAL ADVISER S DECLARATION (to be completed by your financial adviser) This section must be completed for the Application to be accepted. 1. Is the transfer from an occupational pension scheme, or any other registered pension scheme that holds safeguarded benefits? 2. Does your firm have the FCA s permission to advise on pension transfers and opt-outs? If no, provide details below of the firm with the pension transfer and opt out authorisation that has provided advice with regard to the transfer: Name and address of firm: - Go to 2 FCA registration number (if known) Part 1 General details This form is designed for making transfer payments to your existing Personal Retirement Account, Additional Contribution Account or Executive Retirement Account. Please insert your Account number P R A A C A E R A 1 of 7

2 A Personal details of the applicant Title (3) Mr Mrs Miss Other Full forename(s) Surname Permanent residential address (Please note that c/o addresses are not acceptable.) Date of birth D d m m 2 0 y y Spouse s/civil partner s* date of birth (if applicable) D d m m 2 0 y y Sex (3) Male Female Marital status (3) Single Married Widowed Divorced Separated Civil partnership* National Insurance number * as defined by the Civil Partnership Act B Investment instructions Please enter your fund choice below. We have a fund choice to suit all investors, based on your attitude to risk and how involved you want to be in the investment selection process. Your financial adviser will be able to help you choose the most suitable funds for you. Minimum of 1% in any one fund, maximum of 10 funds. Fund manager Full fund name Whole % Total 100% I wish this investment instruction to apply to all transfers detailed in this application. (3) If you have ticked, please supply your different fund selection(s) on a separate sheet clearly indicating which transfer(s) apply to each instruction. If you do not enter complete investment instructions, Old Mutual Wealth reserves the right to allocate part or all of the investment as appropriate to the Professional Sterling Deposit Fund. Old Mutual Wealth offers a Phased Investment and Portfolio Rebalancing Service. Full details of these are available in your phased fund choice portfolio rebalancing programme for Old Mutual Wealth bonds and pensions, or from your financial adviser. If you require an individually tailored Portfolio Rebalancing Service or Phased Investment you must complete instructions for the life and pension portfolio rebalancing or the phased investment form in the above document and submit it with this application. 2 of 7

3 C Benefits payable on death You must complete this section. If you die before drawing pension benefits, the value of the fund may provide benefits in line with regulations. The beneficiaries will be determined at the discretion of Old Mutual Wealth Life Assurance Limited (the Scheme Administrator) in respect of any funds. It is, however, advisable that the Scheme Administrator has guidance about your wishes. You can suggest beneficiaries below. You must complete this section If you die before drawing pension benefits, the value of the fund may provide benefits as described below, in line with regulations. Discretionary death benefits If you wish your beneficiaries to choose one of the following benefits, enter their details in the box below. If you wish to suggest more than one beneficiary, please enter the proportion payable to each. Your instructions will be carried out at the discretion of the Scheme Administrator. The benefits your beneficiaries could choose are: payment of a lump sum (less tax for funds held after age 75 or on any value in excess of your Lifetime Allowance) this option is the only one available where the beneficiary is a trust for the capital value (less tax for funds held after age 75 or on any tax charge on any value in excess of your Lifetime Allowance) to provide pension income as allowed by legislation to buy a lifetime annuity. Alternatively, you can nominate a registered charity to receive payment of a lump sum, which would be payable tax-free unless you have any surviving dependants. I understand that the Scheme Administrator Beneficiary has absolute discretion, but in the event of my death I should like the Scheme Administrator to consider making any payments to: Name* Address % * State the actual names of any beneficiaries. For example, we cannot accept my husband/wife or ambiguous nominations. 100% 3 of 7

4 Part 2 Transfer payments Please note: a) Old Mutual Wealth will accept transfers from UK registered pension schemes with the exception of transfers from unfunded final salary pension schemes, and block transfers to protect tax free cash and/or a protected early retirement age. The specific agreement of Old Mutual Wealth is required before we can accept transfer payments from an overseas source. b) Where any benefit under the transferring scheme/contract is in payment, please complete an application form for the Old Mutual Wealth Collective Retirement Account for existing pension fund withdrawal arrangements. c) Minimum transfer payment 500. A Transferring scheme details Please complete this table in relation to the plan(s) you wish to transfer. 1 Transfer number 2 1. Amount of transfer payment Does this represent the full value of the plan you wish to transfer? If, we will request a partial transfer for the amount above. 2. Transferring scheme provider 3. Plan number 4. Is the transfer from an occupational pension scheme? Please complete this table in relation to the plan(s) you wish to transfer. 3 Transfer number 4 1. Amount of transfer payment Does this represent the full value of the plan you wish to transfer? If, we will request a partial transfer for the amount above. 2. Transferring scheme provider 3. Plan number 4. Is the transfer from an occupational pension scheme? Before we can accept the transfer payment, the Administrator will be required to complete the Declaration in section C of Part 2. 4 of 7

5 B Declaration, application and Personal Data Statement You must complete this section. Any omission or misstatement of a material fact in this application form could affect the payment of benefits under the arrangements comprising the Personal Retirement Account. A material fact is one which is likely to influence the assessment and acceptance of this 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 a) I authorise and instruct the current provider(s) to transfer funds from the plan(s) listed in this application directly to Old Mutual Wealth. Where the current provider(s) has asked me to give them any original policy document(s) in return for the transfer of these funds and I am unable to do so, I promise that I will be responsible for any losses and/or expenses which are as a result, and which any reasonable person would consider to be the probable result, of any untrue, misleading or inaccurate information deliberately or carelessly given by me, or on my behalf, either in this form or with respect to the benefits from the plan. b) I authorise the current provider(s) to release all necessary information to Old Mutual Wealth to enable the transfer of funds to Old Mutual Wealth. c) I authorise the current provider(s) to obtain from and release to the financial adviser named in this application any additional information that may be required to enable the transfer of funds. d) If an employer is paying contributions to any of the plans listed in this application, I authorise the current provider(s) to release to that employer any relevant information in connection with the transfer of funds from the relevant plan(s). e) Until this application is accepted and complete Old Mutual Wealth s responsibility is limited to the return of the total payment(s) to the current provider(s). f) Where the payment(s) made to Old Mutual Wealth represent(s) all of the funds under the plan(s) listed in this application, then payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from the plan(s) listed. g) Where the payment(s) made to Old Mutual Wealth represent(s) part of the funds under the plan(s) listed in this application, then the payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from that part of the plan(s) represented by the payment(s). h) I promise to accept responsibility in respect of any claims, losses and expenses that Old Mutual Wealth and the current provider(s) may incur as a result of any incorrect information provided by me in this application or of any failure on my part to comply with any aspect of this application. i) I agree to supply information relevant to the Personal Retirement Account required by the Scheme Administrator from time to time. j) If I have taken benefits from any pension arrangement, with the current, or any pension provider, in a way that means I am subject to the Money Purchase Annual Allowance (MPAA), I will supply the date the MPAA first applied to me. Application I understand that the Account will comprise additional arrangements for each transfer payment(s) in accordance with the Terms and Conditions of the Account concerned. Personal Data Statement - consent by Applicant To: OLD MUTUAL WEALTH LIFE ASSURANCE LIMITED I agree that you may use my personal data including any sensitive personal data ( my data ) to process my application and to service my plan. I confirm that the beneficiary/each beneficiary and/or my spouse, civil partner or dependant referred to in this application (or parent where parental consent is required if a beneficiary/each beneficiary is a dependant) consents and agrees to my acting as their agent for the purposes of their personal data provided within the application being returned to you for administration of my plan. I understand that: You may provide my data, by electronic or other means, to: other companies within the Old Mutual Wealth and Old Mutual groups of companies if you regard this as necessary to service my plan my adviser a third party to verify my identity in line with money laundering or other requirements which may involve carrying out checks with credit reference databases third parties who perform tasks for you to help you service my plan. These third parties may be based in countries outside the EEA. I understand that these countries may not have laws to protect my data equivalent to those of the UK. However, I understand that you will ensure that any such third parties agree to treat my data with the same level of protection as if you were dealing with it. To prevent and detect fraud you may: share my data with other organisations, including the police check and/or file my data with fraud prevention agencies and databases, and if I give you false or inaccurate information and you suspect fraud, you will record this. You and other companies within the Old Mutual Wealth and Old Mutual groups of companies may use my data for assessment and statistical analysis purposes. My data may be made available to third parties where required by law, court order or regulation. On payment of a small fee, I am entitled to receive a copy of my data which is subject to the Data Protection Act I also have the right to require you to correct any inaccuracies in my data. In such circumstances I can contact you at Old Mutual Life Assurance Limited, Old Mutual House, Portland Terrace, Southampton, SO14 7AY. Signature of Applicant Date D d m m 2 0 y y The Scheme Administrator undertakes on behalf of Old Mutual Wealth Life Assurance Limited to administer the Scheme in accordance with the Rules. A copy of this completed application form and the Member s Guide are available on request. *SIGPPP01* 5 of 7

6 Transfer of pension benefits to Old Mutual Wealth If your application includes more than two transfers, please use a photocopy of this page. Dear Sir or Madam Name of address Postcode Policy number (if applicable) Please accept this letter as my authority to pay the transfer value to Old Mutual Wealth. This is to provide me with added benefits in the receiving scheme instead of under your scheme. I authorise you to provide Old Mutual Wealth with all the information they need to accept the transfer value. I discharge you from providing benefits for me under the above-named scheme after payment of the transfer value. You have confirmed to me that you have calculated the transfer value based on equal benefits for men and women since 17 May This is in line with the European Court of Justice s rulings on equal treatment. I understand that I have no further claim against the trustees, administrators or managers of the transferring scheme. Yours faithfully Signature Date D d m m 2 0 y y Full name Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number VAT number When printed by Old Mutual 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. PDF3093/ /vember 2015 Dear Sir or Madam Name of address Policy number (if applicable) Postcode Please accept this letter as my authority to pay the transfer value to Old Mutual Wealth. This is to provide me with added benefits in the receiving scheme instead of under your scheme. I authorise you to provide Old Mutual Wealth with all the information they need to accept the transfer value. I discharge you from providing benefits for me under the above-named scheme after payment of the transfer value. You have confirmed to me that you have calculated the transfer value based on equal benefits for men and women since 17 May This is in line with the European Court of Justice s rulings on equal treatment. I understand that I have no further claim against the trustees, administrators or managers of the transferring scheme. Yours faithfully Signature Date D d m m 2 0 y y Full name Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number VAT number When printed by Old Mutual 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. PDF3093/ /vember of 7

7 Checklist (3) Have you completed all relevant sections and signed section B in Part 2? Have you initialled any amendments or corrections? For transfer payments, have you signed the letters of authority? Have you enclosed a copy of the Earmarking Order, if applicable? Old Mutual Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: F: Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number VAT number When printed by Old Mutual 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. PDF3093/ /vember of 7