EMPLOYEE APPLICATION FORM LOCAL AUTHORITY AVC FOR OFFICE USE ONLY. Agency Number. Referral Type. Introducer Code. Vantive Lead ID

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1 EMPLOYEE APPLICATION FORM LOCAL AUTHORITY AVC Agency Number FOR OFFICE USE ONLY Referral Type Vantive Lead ID Introducer Code (if different from above) Campaign Code SB Code S B Branch Sort Code

2 Please ensure all sections of the form are completed and both the employee and employer declarations are signed and dated. A. YOUR DETAILS 1. Your title Mr Mrs Miss Ms Other (please specify) 2. Your surname 3. Your first name(s) 4. Your address (see note 1) Postcode 5. Country (see note 2) Nationality Country of residence 6. Are you Male Female 7. Your marital status Single Married/in a registered civil partnership Separated Divorced/registered civil partnership dissolved Widowed/a surviving registered civil partner 8. Your date of birth (DD MM YYYY) 9. Your address Sending personal information by is not secure. Only include your address if you agree to Scottish Widows sending you s. 10. Your phone number 11. Your National Insurance Number (see note 3) What is your selected retiring age? (see note 4) B. YOUR PAYMENTS 1. Regular payments By you from your salary (see note 5) or % of salary Which month would you like your first payment to be taken? (see note 6) NOTES 1) This should be your permanent residential address. We will send all correspondence to this address. Please ensure the postcode is provided. 2) Please ensure you complete if your address is outside England/Scotland/Wales and N.Ireland. 3) Your National Insurance number can be found on a payslip or a P60, or on a tax return. It is essential that you provide it, otherwise we are unable to accept contributions and cannot process your application. If you cannot find your National Insurance number please phone the HM Revenue & Customs Enquiry helpline on ) You may choose a specific retirement age which must be between the ages of 55 and 75. Usually the selected retirement age is the same as the normal retiring age from your employer s main pension scheme. It is possible, however, to have different ages. 5) Your AVC will be a fixed amount which will only change when you tell your employer and they tell Scottish Widows. The fixed contribution can either be a monetary amount or a percentage of your salary at the date you joined the Scheme. The minimum amount is normally 20 per month. Contact your Scheme Administrator for further details. For plans taken out up to 31st March 2014 (inclusive), the maximum amount you can contribute to AVCs in each job where you pay into the LGPS (Local Government Pension Scheme) is 50% of the pensionable pay of that employment or an amount equal to 50% of the pensionable pay of that employment. For plans taken out from 1st April 2014 (inclusive), the maximum amount you can contribute to AVCs in each job where you pay into the LGPS (Local Government Pension Scheme) is 100% of the pensionable pay of that employment or an amount equal to 100% of the pensionable pay of that employment. 6) Your AVC contributions will be collected by your employer and forwarded to Scottish Widows. This will usually be at the same time as any contributions to your employer s main pension scheme. The first payment will normally be collected in the month that the application is received, or the following month.

3 C. YOUR CHOICE OF FUNDS My payments should be invested in the following proportions (a list of the available funds can be found in the Local Authority AVC Employee Pack enclosed). Fund % Split Total 100% Please note: you can only invest in a maximum of 10 funds at any one time. There may be restrictions on the amount that can be invested in certain funds. Please contact us for details of any restrictions that may apply on the amount that can be invested. We may change the selection of funds that we make available. You can change your investment choice at any time. D. DECLARATION I apply to become a member of the Scheme and agree to abide by the Rules of the employer s main pension scheme. I confirm that I have answered all the questions honestly and fully. I consent to the Trustees holding personal data about me and agree to that information being processed by or on behalf of the Trustees in order to administer the scheme. I also agree to that information being passed to insurance companies and/or other third parties and by them to me for the purposes of the scheme by electronic or other means. I understand that this data may include information about my physical or mental health or personal relationships. In addition, information, including information about the value of my Scheme benefits, may be disclosed to the Scheme adviser. I have received the Important Notes for Applications document and the Key Features document. For your own benefit and protection, please read these documents before you sign this application. Scottish Widows will rely on them when administering your contract. If you do not understand any point, please let us know. Marketing Choices We would like to keep you up to date on products and offers that may be of interest to you. Please select how you would like to hear from us below. These choices won t affect any necessary information we need to send you such as statements and, don t worry, you can change your mind and update your preferences at any time. SCOTTISH WIDOWS WEBSITES You may see relevant messages when you log in to our online services. If you choose no, you may still see messages, but they will not be tailored to you. Yes No Yes No POST Yes No DEVICE NOTIFICATIONS As we develop mobile applications you ll receive relevant notifications to your mobile device Yes No TEXT MESSAGES Yes No PHONE Yes No

4 By saying yes, you are giving consent for Scottish Widows to use your personal information to send you relevant offers and information about our products. Scottish Widows includes the following legal entities: Scottish Widows Ltd, Scottish Widows Unit Trust Managers Limited, Scottish Widows Administration Services Limited and HBOS Investment Fund Managers Limited. Occasionally we will send you selected offers from other companies within Lloyds Banking Group that may be relevant to you. Signature Date (DD MM YYYY) THE FOLLOWING SECTIONS SHOULD BE COMPLETED BY YOUR EMPLOYER. E. SCHEME DETAILS 1. LGPS AVC Scheme name 2. Local Government Employer s name 3. Section to which the employee is to be added (if applicable) 4. Employer s address Postcode F. EMPLOYEE S EMPLOYMENT DETAILS 1. What is the employee s annual pensionable salary? 2. What is the employee s pay number or staff number? (if you provide a reference number it will appear on any contribution list) 3. How is the employee paid? (please tick the appropriate box) Weekly Monthly G. DECLARATION BY EMPLOYER I request Scottish Widows Limited to issue a policy in accordance with the above particulars. Signature Name (Please Print) Date (DD MM YYYY) On behalf of (Insert name of the employer)

5 Scottish Widows Limited. Registered in England and Wales No Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number A 03/18