Aviva Personal Pension Application Form

Transcription

1 Aviva Personal Pension Application Form to Aviva Life & Pensions UK Limited ( Aviva ) Please note carefully This is a legal document and together with the policy conditions (which are available on request) and policy schedule forms part of any subsequent contract with Aviva. All sections must be fully completed and any alterations initialled by the signatory/signatories. A copy of the completed application form, as submitted on your behalf to Aviva, is available on written request. 1. Financial Broker Details 1. Agency Number 2. Name of Financial Broker 3. Financial Broker s Address 4. Financial Broker s Phone Number 5. Aviva Broker Consultant Name Please complete this form in BLOCK CAPITALS Contributions will not be invested in the chosen funds until we have received all of our requirements. 2. Eligibility Details a. Are you self-employed or a partner acting in some trade, profession or occupation? Yes No b. Are you an employed person or the holder of an office of employment? Yes No If Yes, is one or more of your occupations non pensionable? Yes No This form is for the selfemployed or people in nonpensionable employment. Eligibility details are required to identify if you are eligible to start an Aviva Personal Pension. 3. Personal Details Title Mr Ms Mrs Other First Name Date of Birth / / Surname Gender Male Female Relationship Status Single Married Separated Divorced Widow(er) Civil Partner Address Contact Phone Number If my application is accepted I would like to only receive my policy documents and notice of the cancellation process through my Aviva Online account. Yes Earnings / Salary Chosen Retirement Age We do require a valid customer address to proceed with the application. Online only correspondence option is only available if a valid address is supplied. If you do not select this online only correspondence option we will assume you want to receive a paper copy of your policy documents. Copies of your policy documents will also be available in your Aviva Online account should you decide to register. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is authorised by the Prudential Regulation Authority in the UK and is regulated by the Central Bank of Ireland for conduct of business rules. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is also regulated in the UK: by the Prudential Regulation Authority for prudential rules and, to a limited extent, by the Financial Conduct Authority for applicable UK conduct rules. Registered Branch Office in Ireland (No ) at One Park Place, Hatch Street, Dublin 2. Tel (01) Web Registered in England ( ) at Wellington Row, York, YO90 1WR.

2 4. Contribution Details Note for Financial Brokers: Please ensure that you complete the Product Details in Section 8 of this application form. Regular Contribution Contribution Frequency and Payment Method Monthly Direct Debit Yearly Direct Debit Single and Regular contributions can only be accepted from an account in the policyholder s name Yearly Cheque Yearly by Electronic Funds Transfer (EFT) Automatic increase in contribution No I understand that unless I have said no to Automatic increase in contribution, my regular contributions will automatically increase each year by 5%. This will take place on the yearly anniversary date of the policy. Details for EFTs Bank: Ulster Bank IBAN: IE26ULSB BIC: ULSBIE2D Contribution amount Single Contribution Payment Method Cheque Contribution amount Transfer Payment Payment Method Cheque Source of funds - EFT Electronic Funds Transfer (EFT) Electronic Funds Transfer (EFT) Please provide details of the bank account from which the funds for the policy were paid unless method of payment is a personal cheque from the applicant s bank account. Transfers can only come from other Revenue approved Personal Pension Plans we cannot accept transfers from Occupational Pension Schemes, Retirement Bonds or Personal Retirement Savings Accounts (PRSAs) The start date must be between the 1st & 28th of the month. Account name Account number IBAN Bank identifier code BIC Contribution amount Start Date for Contributions / / Is the transfer payment from an existing Aviva Ireland pension? Yes No If Yes please the Transfer Form to retirement.solutions@aviva.com If No is the transfer payment from an overseas pension plan? Yes If Yes, from which region does the transfer originate from? No Australia USA Europe Africa Other Name of the scheme / contract s trustee / administrator / custodian / manager / insurance company authorised to allow the transfer to Aviva s Personal Pension Plan Transfers cannot originate from the UK.

3 Address of the scheme / contract s trustee / administrator / custodian / manager / insurance company authorised to allow the transfer to Aviva s Personal Pension Plan Name of Contact Person address Telephone Number Overseas Transfer Declaration (only relevant where your transfer is coming from an overseas pension scheme) I wish to transfer the assets of my overseas pension arrangement to the Aviva Personal Pension. I agree to allow Aviva to obtain any information it regards as relevant from the Company and / or Contact Person, named above, in order to facilitate the transfer of my fund. I authorise the Company and / or Contact Person named above to give Aviva any information relevant to this transfer. Signature Date To be signed by the Customer / / Please sign and date 5. Fund Choice - select option (a) or (b) only (a) Fund Choice managed by you / for you Please complete details of your fund choice and the proportion to be invested in each fund. Please note, we can only accept whole percentage numbers. (b) Fund Name Lifestyle Strategies Regular Contribution Single Contribution Transfer Payment 100% 100% 100% Lifestyling strategies use an automatic system that, over time, switches your pension fund from higher risk funds to lower risk funds as you approach retirement. This in effect means that the pension fund you have built up is gradually de-risked over a set period of time prior to your retirement age. Please select one option below: Aviva Investors Annuity Aviva Investors ARF Legal & General Annuity You can choose to invest in any of the fund options listed in our fund guide, Your Investment Options. There is a minimum investment of 10 per fund. Please see our Fund Guide, Your Investment Options for full details on all of our funds, and speak to your Financial Broker. It is important that you clearly write the full fund name when making a selection to avoid any delay in processing your application. For full details of the Lifestyling strategies available through the Aviva Personal Pension, please see the separate Lifestyle Strategies from Aviva brochure and speak to your financial broker. Legal & General ARF Merrion Annuity Merrion ARF

4 6. Data Protection Notice Please read this Data Protection Notice carefully before you complete the Declarations 1. Introduction We collect and use personal information about individuals so that we can provide insurance and pension products requested by our customers. This Data Protection Notice explains the most important aspects of how we use personal information and what rights individuals have. You can get more information about the terms we use and view our Privacy Policy at or request a copy by writing to the Data Protection Officer, Aviva Life & Pensions UK Limited, One Park Place, Hatch Street, Dublin 2 or call us on (01) This Data Protection Notice applies mainly to the Applicant/Policy Owner (referred to in this Data Protection Notice as you and your ). The data controller responsible for processing this personal information is Aviva Life & Pensions UK Limited ( we, us, our ) as the provider of the product. Your intermediary/financial broker (who is responsible for the sale and suitability of the product) will be an additional data controller in obtaining and maintaining the product. 2. Type of Information/Where Collected We collect personal information from you and any relevant third parties (including that authorised by the Declarations) under and in relation to this Application and the administration of the policy, to include processing benefits and complaints. You don t have to provide us with any personal information, but if you don t provide the information we need we may not be able to proceed with your application or any claim you make. We will let you know what information is required to proceed with your application or any claim you make. We may also use personal information about people other than you e.g. limited personal information on administrators/managers of a relevant pension arrangement, your nominated representatives, personal representatives and your attorneys (under powers of attorney). If you are providing personal information about another person we require you to let them know what information you ve shared with us, share with them this Data Protection Notice and obtain their confirmation that they have read and understand this Data Protection Notice. If you or they have any queries or concerns please contact us in one of the ways described below. We may also collect personal information: already held about you within the Aviva Group (identified in our Privacy Policy), including details from previous policies of insurance and claims; from your intermediary, financial broker or other nominated representative; from publicly available information including social media websites and online content, newspaper articles, tv, radio and other media content, court judgements, public registers and specialist databases (for example Companies Registration Office, Vision-net, Oracle, Dow Jones, SoloCheck) and (only for purposes of verifying your identity) electoral register; and from other insurance companies and other pension providers.

5 3. Legal Basis and Purposes for Use The legal basis we rely on to process your personal information and the purposes for which we collect and use personal information are summarised below. Further information is set out in our Privacy Policy. Legal Basis for Use In order to take steps prior to entering into a contract i.e. the insurance policy For the performance of a contract i.e. the insurance policy For compliance with a legal obligation To protect your vital interests Legitimate Interests (of Aviva and/or the Policy Owners) Legitimate Interests (of Aviva) Legitimate Interests (of Aviva) Legitimate Interests (of Aviva) To carry out other activities that are in the public interest Purposes for Use To consider whether to accept this application and consider the related administrative and regulatory requirements e.g. eligibility for a personal pension. To administer the policy for you in accordance with the policy conditions (a copy of which are available on request from us or the intermediary/financial broker), including to evaluate, validate and/or process transfers, benefit payments, policy options and complaints and the prevention and detection of fraud in respect of the policy. Compliance by us with all relevant legal and regulatory obligations. This will only arise in exceptional circumstances where we may use and/or disclose information to protect you, for example, Ward of Court applications or equivalent processes. We may process personal information of people other than the Policy Owners to administer the policy, including processing transfers, benefit payments, policy options and complaints for the benefit of the Policy Owner. To support the legitimate interest that we have as a business in managing our legal affairs including exercising our legal rights and defending claims; and managing our business effectively e.g. with third party service suppliers. To support other legitimate interests that we have as a business and that the insurance industry at large has to manage security including preventing, detecting, investigating and/ or protecting our customers and ourselves from financial crime, theft and fraud. Our legitimate interests to better understand our customers and improve service enhancement and business performance, this includes customer analytics; market research; processing management information; reporting (including Aviva Group reporting) for compliance, audit, statistical or research purposes; staff training; providing online services; and in the event of any portfolio transfer, merger, acquisition, disposal or other such transaction relating to our business. Where practical we will anonymise the data we analyse. We may need to use personal information to verify your identity and carry out anti-money laundering checks. Your Right to Object Please note that you have a right to object to processing of your personal information where that processing is carried out on the grounds of legitimate interests or public interest. If you do object: we will have an opportunity to demonstrate that there are compelling legitimate grounds which override your rights and freedoms or that processing is necessary for the establishment, exercise or defence of legal claims; a successful objection may have consequences for our continued administration of the policy (e.g. prevent us assessing future claims and/or the policy may be cancelled) and we can discuss these if you want to object.

6 4. Who we share your information with Where relevant, we may share personal information with: 1. Other Aviva Group companies, agents, professional advisers acting for us (e.g. lawyers) and third party service providers. 2. The intermediary/financial broker and at its request, third party service providers who provide services to the intermediary/financial broker (e.g. software providers who give brokers an overview of customer information across different insurance providers). 3. Your agents, nominated representatives and other third parties relevant to you and/or the policy, including your legal advisers, other insurance companies and relevant pension providers. 4. If we are required to do so to comply with a relevant legal or regulatory obligation: with regulatory bodies, law enforcement bodies, government departments including UK Financial Conduct Authority, UK Prudential Regulatory Authority, Central Bank of Ireland, Financial Services and Pensions Ombudsman, Revenue Commissioners/Inspector of Taxes, Gardaí, Criminal Assets Bureau, Data Protection Commission and National Treasury Management Agency. Some of the organisations we share information with are located outside of the European Economic Area ( EEA ), including India. We ll take steps to ensure that any such transfer of information outside of the EEA is managed to protect your privacy rights. For more information on this please see our Privacy Policy or contact us. 5. How long we keep your personal information for We maintain a retention policy to ensure we keep personal information only for as long as we reasonably need it please see our Privacy Policy for further details. We need to retain personal information for the period necessary to administer the policy and as long as is required/ permitted by law and/or in respect of any potential dispute in relation to the policy. Currently this would commonly be 7 years from the date when the customer relationship ceases. 6. Your rights You have various rights in relation to your personal information, including the right to: request access to your personal information; correct any mistakes on our records; erase or restrict records where they are no longer required; object to our use of personal information based on legitimate interests or public interests; ask not to be subject to solely automated decision making if the decision produces legal or other significant effects on you; and move (in a structured, commonly used and machine-readable format) certain data to other providers (data portability). We will respond to your request in writing, or orally if requested, as soon as practicable and in any event not more than within one month after receipt of your request. In exceptional cases, we may extend this period by two months and we will tell you why. We may request proof of identification to verify your request. For more details in relation to your rights, including how to exercise them, please see our Privacy Policy or contact us using the details set out below. 7. Contacting us If you have any questions about how we use personal information, manage personal information within our business or if you want to exercise your rights stated above, please contact our Data Protection Officer by either ing them at DPO@ aviva.com, writing to the Data Protection Officer, Aviva, One Park Place, Hatch Street, Dublin 2 or call us at (01) If you have a complaint or concern about how we use your personal information please contact us in the first instance and we will attempt to resolve the issue as soon as possible. You also have the right to lodge a complaint with the Office of the Data Protection Commission or any other relevant data protection authority. Please see our Privacy Policy (available at or on request) or contact us for further details.

7 7. Declarations Declaration under Regulation 6(3) of the Life Assurance (Provision of Information) Regulations 2001 WARNING If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance intermediary. Ref. Policy Number Declaration of Insurer or Intermediary I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the applicant has been provided with the information specified in Schedule 1 to those Regulations and that I have advised the client as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction and of possible financial loss as a result of such replacement. Financial Broker Signature Name of Insurer or intermediary Please sign and date Date / / Declaration of Customer I apply to Aviva for the Aviva Personal Pension and declare that: 1. I have received in writing the information specified in the above declaration of insurer or intermediary. 2. I am eligible to apply for the proposed Aviva Personal Pension. 3. I consent to Aviva, verbally or otherwise, seeking and receiving additional information that isn t provided on the application or where further information is required in order to process the application and such information will be deemed to be incorporated into this application and I hereby authorise the trustees, administrators and life assurance providers of relevant pension arrangements with information relevant to this application and my agents to provide such information to Aviva. 4. The information in this application for this Aviva Personal Pension is true and complete. 5. I agree that without further communication to me Aviva may, if they accept this application, issue a policy comprising policy conditions on Aviva s standard terms for the Aviva Personal Pension (a copy of which has been made available) and a policy schedule as regards the particulars of the policy such as the contribution amounts, fund choices and charges. 6. I agree that the policy conditions and policy schedule together with the information in this application will form the contract between Aviva and me. 7. I agree and understand that even if a contribution is tendered or a direct debit mandate is signed, no binding contract is created until Aviva has issued the policy documents. 8. I am resident for tax purposes in the Republic of Ireland and have an address in the Republic of Ireland. I undertake to inform Aviva of any change in my country of residence during the life of the policy. 9. I am aware of the retirement options available from a Personal Pension Plan and understand that these may be different to those offered in the existing pension arrangement from which any transfer is being paid. In particular but without limitation I understand that if the scheme which is being transferred offered guaranteed benefits, the Aviva Personal Pension will not provide any such or guarantees the fund value can fall as well as rise.

8 10. I further understand that no benefit under the contract shall be capable of being surrendered, assigned or commuted except as provided by Section 784 and 785 of the Taxes Consolidation Act, I agree and understand that Aviva s processes may involve electronic means including, but not limited to, data entered online, the capturing of my/our signature(s) on an electronic device, the use of electronic signature or the use of a signature-free process; Aviva s processes may also (even where commenced on-line) involve manual processes and/or require wet ink signing of documents at certain points. 12. Where I have agreed to only receive my policy documents through Aviva Online, I agree to Aviva making these available to me online and acknowledge that I will need to register with Aviva Online (or if I am already registered I will need to add this as an additional policy to my existing account) to access my policy documents. I confirm that I have the necessary technical ability and resources to access these policy documents and acknowledge Aviva will consider these policy documents delivered when available to me in my Aviva Online account (and not on the day that I actually view the documents). 13. I have read and understand the Data Protection Notice. Where I am providing information about another person (e.g. administrator/manager of transferring pension arrangement, nominated representatives or attorneys), I confirm that I have: let them know what information I have shared with Aviva; shared the Data Protection Notice with them; and obtained their confirmation that they have read and understand the Data Protection Notice. I understand that Aviva require for the purposes of this Application that I have done so. Signature of customer Please sign and date Date / /

9 8. Product Details (To be completed by Financial Broker) (a) Aviva Personal Pension Range 1 Regular Contributions % Note: this can range from Nil to 5% in bands of 0.25%. Product Codes can be found in Pensions from Aviva - Financial broker Booklet Single Contribution Transfer Payments % Note: this can range from Nil to 5% in bands of 0.25%. % Note: this can range from Nil to 5% in bands of 0.25%. Fund Based Commission % Note: this is available in bands of 0.05% up to 0.50% and then in bands of 0.25% from 0.50% to 1.00%. (b) Aviva Personal Pension Range 2 Regular Contributions Please specify the following: Initial Commission % Renewal Commission % Single Contribution % Note: this can range from Nil to 5% in bands of 0.25%. Regular Contributions Initial commission is a maximum of 15% (based on 1.25% x term to a maximum retirement age of 68). Renewal commission can be between 0% and 4%. Transfer Payments % Note: this can range from Nil to 5% in bands of 0.25%. Fund Based Commission % Note: this is available in bands of 0.05% up to 0.50% and then in bands of 0.25% from 0.50% to 1.00%. (c) Aviva Personal Pension Range 3 Regular Contributions only Please specify the following: Bullet commission: % Fund Based Commission Bullet commission: Please specify either 30% or 40%. % Note: this is available in bands of 0.05% up to 0.50% and then in bands of 0.25% from 0.50% to 1.00%

10 Application No. SEPA DIRECT DEBIT MANDATE SEPA Direct Debit Mandate Unique Mandate Reference (UMR) To be completed by Aviva Life & Pensions UK Limited By signing this mandate form, you authorise (A) Aviva Life & Pensions UK Limited to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Aviva Life & Pensions UK Limited. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that can be obtained from your bank. Please complete all fields marked* Name(s) of Account holder(s) * Account number IBAN* Bank identifier code BIC* Creditor s name Aviva Life & Pensions UK Limited Creditor identifier I E 7 4 Z Z Z Creditor address One Park Place, Hatch Street, Dublin 2, Ireland. This mandate is in respect of a recurring payment. x x Signature* Signature* Date D D M M Y Y Y Y Location Please return this mandate to Aviva Life & Pensions UK Limited trading as Aviva Life & Pensions Ireland, One Park Place, Hatch Street, Dublin 2. Please note: Banks may refuse to accept instructions to pay Direct Debits from some types of accounts, usually savings or deposit accounts. If in doubt check with your bank. Aviva Life & Pensions UK Limited may combine the Direct Debits for this mandate with those from any other mandate(s) which you have signed in their favour and which may be payable to them within the same calendar month. Payment amounts may vary from time to time. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is authorised by the Prudential Regulation Authority in the UK and is regulated by the Central Bank of Ireland for conduct of business rules. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is also regulated in the UK: by the Prudential Regulation Authority for prudential rules and, to a limited extent, by the Financial Conduct Authority for applicable UK conduct rules. Registered Branch Office in Ireland (No ) at One Park Place, Hatch Street, Dublin 2. Tel (01) Web Registered in England ( ) at Wellington Row, York, YO90 1WR