For UK individuals. FINANCIAL ADVISER DETAILS NOTES BEFORE YOU COMPLETE YOUR APPLICATION

Transcription

1 STARTING YOUR SELECT LIFESTYLE BOND A powerful combination of the International Select Bond, the Lifestyle Trust and Old Mutual International Trust Company For UK individuals. This document was last reviewed in November Please confirm with your financial adviser that this is the most up-to-date document for your needs. FINANCIAL ADVISER DETAILS Old Mutual International account number Adviser company name Name of financial adviser Adviser company address Telephone number address NOTES BEFORE YOU COMPLETE YOUR APPLICATION All references to Old Mutual International, we, us and our in this application form mean Old Mutual International Isle of Man Limited, who are the providers of the International Select Bond which forms part of the Select Lifestyle Bond. Important information for you the applicant Before completing the application form, please make sure you have received and read through the relevant product literature: Key features of your International Select Bond and personal illustration Details of your International Select Bond Redemption (ref ISBRv1) or Details of your International Select Bond Life (ref ISBLv1) Policy Terms Key Information Document (KID) for the International Select Bond Redemption or Key Information Document (KID) for the International Select Bond Life and asset Key Information Document(s) (KIDs) and, where appropriate, the asset Key Investor Information Document(s) (KIIDs). Select Lifestyle Bond brochure Explaining your Portfolio Bond fees and charges Old Mutual International Trust Company Limited client agreement (including terms of business, current fee scales and client money information sheet) continued Your financial adviser will be able to provide you with the relevant Select Lifestyle Bond literature. 1 of 28

2 NOTES BEFORE YOU COMPLETE YOUR APPLICATION (CONTINUED) To complete this form: Use black or blue ink Use CAPITAL LETTERS only Do not use correction fluid cross through any amendments (initialled by the applicant) NOTE TAXATION INFORMATION Under Automatic Exchange of Information (AEOI) regulations, Old Mutual International is required to obtain information about an applicant s tax status. To enable us to comply with these regulations, when submitting this application form you must also submit the Taxation declaration and self-certification for individual investors form. Completion and submission of a self-certification is mandatory and failure to provide one could result in your Portfolio Bond being reported under AEOI by default. If any of the information contained in the self-certification changes, please advise Old Mutual International promptly so we can determine if a new self-certification is required. ADDITIONAL PAGES/ PHOTOCOPIED PAGES If additional pages are added, each separate page must be initialled by the applicant. FINANCIAL ADVICE We only sell our products through financial advisers as we believe it is important that 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 Old Mutual International. You are responsible for their actions or omissions. CANCELLATION RIGHTS You have the right to change your mind and cancel your policy by giving notice in writing. Notice must be received by Old Mutual International within 30 days from the date you receive your Policy Schedule. If you decide to cancel, we will give you your money back. If the value of your investment has fallen, you may not get back the full amount you paid in. Any Old Mutual International and Old Mutual International Trust Company charges will be refunded in full. If, at your request, we have facilitated a fee for advice given to you by your financial adviser and you decide to cancel your policy, we cannot reclaim or refund the fee. The fee agreement is between you and your financial adviser, not Old Mutual International, and it is up to you to discuss the reclaim of the fee from your financial adviser. BANKING DETAILS Sterling payments From UK banks (CHAPS payments) Sort code: Bank: Isle of Man Bank, East Region, 2 Athol Street, Douglas, Isle of Man Beneficiary: Old Mutual International Isle of Man Limited Account number : Cheque: Make payable to Old Mutual International Isle of Man From non-uk banks (SWIFT payments) SWIFT code: RBOSIMD2XXX Sort code: Bank: Isle of Man Bank, East Region, 2 Athol Street, Douglas, Isle of Man Beneficiary: Old Mutual International Isle of Man Limited IBAN: GB94NWBK Other currency payments (SWIFT payments) Payments should be made to Old Mutual International Isle of Man Limited s accounts held with National Westminster Bank, London. SWIFT code: NWBKGB2LXXX Bank: National Westminster Bank, London IBAN: (select as applicable, see below) 1. US dollar IBAN GB05NWBK Euro IBAN GB63NWBK A TYPE OF APPLICATION Type of bond Please indicate which type of BOND you are applying for: (3) The type of bond cannot be changed after it has been set up. Life assurance This is called the International Select Bond Life Capital redemption This is called the International Select Bond Redemption 2 of 28

3 B Details of THE APPLICANT The applicant must be at least 18 years old and no older than 90 years. The applicant THE SETTLOR OF THE TRUST Title Mr Mrs Miss Other Forename Middle name(s) Last name Previous name or alias Gender Male Female Date of birth D D M M Y Y Y Y Nationality Dual nationality (if applicable) Passport/national identity card number Residential/home address (inc. post code) We do not accept c/o or PO Box addresses Correspondence address Country Country Individual address Contact number (Inc. area code) Employment status Employed Self Employed Not employed Retired* (*please include details of your previous employer or own company) Company Name Full address of company Country Company website (if any) Occupation Last year s gross salary Salary currency US$ Other (please state) Last year s bonus Bonus currency US$ Other (please state) If you receive income from another source (e.g. dividends, interest; please provide details here) continued 3 of 28

4 B Details of THE APPLICANT (continued) REASON FOR INVESTMENT Reason for investment (if different from purpose of the trust in section I) politically exposed person (PEP) If the applicant, or any other party connected to this application either now or in the past/future, could be classed as a politically exposed person (PEP), or connected with a PEP, please provide details. A politically exposed person (PEP) is someone holding an important public position, or a person clearly related to them. Examples of these are: Heads of State or Government Judicial or military officials Senior executives of publicly owned corporations Senior politicians Senior Government officials Important political officials. PEP Name Connection to applicant Details of PEP C DETAILS OF THE LIFE/ LIVES ASSURED (the settlor or their SPOUSE/CIVIL PARTNER* are not permitted to be lives assured under the Select Lifestyle Bond) NOTE Do not complete this section if you have selected capital redemption in section A as there are no lives assured on a capital redemption bond and we will not record the details if you fill in this section in error. Minimum age for life assured is three months and maximum age is 90 years FIRST LIFE ASSURED (IF ANY) SECOND LIFE ASSURED (IF ANY) Title Mr Mrs Miss Mr Mrs Miss Other Other Forename Middle name(s) Last name Previous name or alias Gender Male Female Male Female Date of birth D D M M Y Y Y Y D D M M Y Y Y Y Nationality Dual nationality (if any) Residential/home address (inc. post code) We do not accept c/o or PO Box addresses Country Country * as defined by civil partners act of 28 continued

5 C DETAILS OF THE LIFE/ LIVES ASSURED (the settlor or their SPOUSE/CIVIL PARTNER* are not permitted to be lives assured under the Select Lifestyle Bond) (continued) NOTE Do not complete this section if you have selected capital redemption in section A as there are no lives assured on a capital redemption bond and we will not record the details if you fill in this section in error. THIRD LIFE ASSURED (IF ANY) FOURTH LIFE ASSURED (IF ANY) Title Mr Mrs Miss Mr Mrs Miss Other (please state) Other (please state) Forename Middle name(s) Last name Previous name or alias Gender Male Female Male Female Date of birth D D M M Y Y Y Y D D M M Y Y Y Y Nationality Dual nationality (if any) Residential/home address (inc. post code) We do not accept c/o or PO Box addresses Country Country * as defined by civil partners act D INVESTMENT DETAILS PREMIUM PAYMENT NOTE Minimum initial investment is 20,000, US$30,000 or 30,000 Currency (3) US$ Amount to be invested Payment method (3) Bank Transfer Cheque policy currency I wish my policy to be valued in (3) US$ NOTE Please note if no currency is entered your policy currency will be pound sterling ( ). The policy currency cannot be changed after the policy is set up. NUMBER OF POLICIES For the Select Lifestyle Bond 1,000 policies are issued as a default. If you would like an alternative number please enter here NOTE You can specify any number of policies but no more than 9,999 policies are available. If you do not specify the number of policies we will issue 1,000 policies. The amount of policies cannot change after your International Select Bond policy has been issued. With the Select Lifestyle Bond, it is important to have enough policies within the International Select Bond to provide flexibility when accessing capital. 5 of 28

6 E SOURCE OF FUNDING and Origin of Wealth BANK DETAILS OF WHERE FUNDS ARE BEING REMITTED FROM The premium payment must come from an account held in the name of the applicant and NOT a third party. If multiple payments are being received, please complete this section for each payment (further space available on following page). BANK DETAILS 1 Payment currency US$ Payment amount Name as stated on bank account Sort code (If applicable) Account number/ IBAN SWIFT or BIC code (If applicable) Bank name Bank s full address Country How long have you held this account years months FURTHER PAYMENTS IF APPLICABLE BANK DETAILS 2 Payment currency US$ Payment amount Name as stated on bank account Sort code (If applicable) Account number/ IBAN SWIFT or BIC code (If applicable) Bank name Bank s full address Country How long have you held this account years months continued 6 of 28

7 E SOURCE OF FUNDING AND ORIGIN OF WEALTH (continued) FURTHER PAYMENTS IF APPLICABLE BANK DETAILS 3 Payment currency US$ Payment amount Name as stated on bank account Sort code (If applicable) Account number/ IBAN SWIFT or BIC code (If applicable) Bank name Bank s full address Country How long have you held this account years months continued 7 of 28

8 E SOURCE OF FUNDING AND ORIGIN OF WEALTH (continued) FULL DETAILS OF ORIGIN OF WEALTH AND INCOME NOTE We need to understand how your initial premium was acquired. Please provide full details of this below DESCRIPTION DETAILS REQUIRED DETAILS Accumulated earned income (including salary, bonus and fees) Number of years income accumulated Name of account where funds have been held Account number Institution where it has been held How long it s been held Has your income been accumulated from the employer detailed in Section B? (If no please provide further details below) Name of employer Yes No Full address of employer Occupation Annual gross salary R e l e v a n t b o n u s d e t a i l s Sale of interest in company Name of company Nature of business Address of company Connection to company (i.e. owner, partner, shareholder, etc.) Total sale amount Date of sale D D M M Y Y Y Y Net amount you received from sale (minus charges, solicitors fees etc.) continued 8 of 28

9 E SOURCE OF FUNDING AND ORIGIN OF WEALTH (continued) DESCRIPTION DETAILS REQUIRED DETAILS Sale of shares/ investments Name of company that held the shares/ investments (i.e. bank, stockbroker or insurance company) Address of the above company How were they sold? (i.e. bank, stockbroker or other agent, if applicable) Description of shares/investments (i.e. government bonds, equities, etc.) Length of time shares/investment held Total amount of sale Date of sale D D M M Y Y Y Y Sale of property If you are not the beneficial owner of this property, please select a different option for Origin of Wealth that is more appropriate Address of property sold (including postcode if applicable) Total sale amount Date of sale D D M M Y Y Y Y Net amount you received from sale Inheritance Donor s name Relationship to donor Date of donor s death D D M M Y Y Y Y Details of inheritance (i.e. cash, property, shares etc.) Amount received Date received D D M M Y Y Y Y Gift Name of person who gave the gift Relationship to donor Reason for gift Description of gift Total amount received Date received D D M M Y Y Y Y continued 9 of 28

10 E SOURCE OF FUNDING AND ORIGIN OF WEALTH (continued) DESCRIPTION DETAILS REQUIRED DETAILS Competition or gambling win Name of organisation How was the money won? Total amount won Date received D D M M Y Y Y Y Maturing investment/policy claim/replacement policy Reason for policy claim or replacement policy (if applicable) Name of company/policy provider Name of person who held the policy Total amount received Surrender penalty incurred (if any) Date received D D M M Y Y Y Y Length of time investment/policy held Compensation Who paid the compensation (i.e. name of organisation or individual) Reason for compensation Total amount received Date received D D M M Y Y Y Y Loan Name of loan provider Address of loan provider Reason for loan Total amount borrowed Date of loan D D M M Y Y Y Y Other Nature of activities generating the wealth Role in relation to above activities Period over which the activities occurred Date received D D M M Y Y Y Y 10 of 28

11 F ASSET CHOICE investment range Please select one of the two investment ranges below. WealthSelect investment range SelfSelect investment range NOTE You can find more information on the WealthSelect and SelfSelect investment ranges in the International Select Bond product brochure. Please note that only assets from either WealthSelect or SelfSelect can be chosen it is not possible to mix assets. However, you can switch between the investment ranges once the policy commences. ASSET IDENTIFIER ISIN ASSET NAME IN FULL BASE CURRENCY OF SECURITY/FUND INVESTMENT % (whole numbers) total In case we need to clarify the asset choice details, please provide us with the following contact details Contact name Contact telephone number including country code Alternate contact telephone number including country code address (continued) 11 of 28

12 F ASSET CHOICE investment range (continued) CHARGE DEDUCTION ASSET The Charge Deduction Asset is an asset that will be used to pay Portfolio Fund Charges and any ongoing advice fees. Where you have chosen assets from the WEALTHSELECT investment range, all of the assets within the Portfolio Fund except the Transaction Account will be regarded as the Charge Deduction Asset. If there is a credit balance in the Transaction Account held with us then we will normally use that value towards payment of your Portfolio Fund Charges. If we are unable to clear the debit balance held in the Transaction Account, then: WEALTHSELECT If you have selected the WEALTHSELECT investment range, any debit balance remaining will be cleared automatically by a proportionate sale across all assets, except the Transaction Account. SELFSELECT If you have selected the SELFSELECT investment range, any debit balance remaining will be cleared by one of three options: (a) sale of a specific asset, (b) sale of the asset with the highest value; or (c) sale of all assets proportionately. Please select your preferred option: (3) a specific asset the highest value asset at the time all assets to be sold proportionately If you want to choose a selected asset, please provide details of the asset below. The asset must be one of the assets you have selected on page 11. Asset identifier ISIN Asset name G OLD MUTUAL INTERNATIONAL CHARGES AND INITIAL ADVISER FEES Old Mutual International charge package code Initial fee to be paid to your financial adviser and facilitated by Old Mutual International Yes No Monetary amount or % How do you want us to pay this fee? Choice 1 before investment in your International Select Bond meaning we will deduct the fee from your lump sum premium payment before the remainder is invested in your International Select Bond. Choice 2 after investment in your International Select Bond meaning we will deduct this fee by making a one-off withdrawal (part surrender) of this amount from your policy after your lump sum premium has been invested. 12 of 28

13 H Investment advice NOTE Please complete one of the following two options. APPOINTMENT OF A DISCRETIONARY ASSET MANAGER (on an advisory basis) If you do not want Old Mutual International to appoint a discretionary asset manager on an advisory basis then leave this section blank. Details of the discretionary asset manager: Name Address Country Discretionary asset manager Regulatory Authority name and licence number The above discretionary asset manager or firm holds regulatory authority to provide investment recommendations to Old Mutual International on its assets that are linked to a Portfolio Fund on an International Select Bond. The discretionary asset manager on behalf of the firm will need to read and sign the declaration on page 17. In return for the investment services, please consider paying the following: Amount to be paid % each year of the value of the trust fund payable quarterly. Currency (3) US$ E INVESTMENT MANDATE 1. Investment strategy Long-term capital growth. 2. Risk criteria 3. Investment restrictions Defensive Neutral Adventurous The assets held may vary according to the current and anticipated market conditions, and over the short term may concentrate on a particular geographical sector or asset type. OR APPOINTMENT OF FUND ADVISER OR DISCRETIONARY ASSET MANAGER (on a discretionary basis) If you wish to appoint a fund adviser and/or a discretionary asset manager on a discretionary basis then you will need to complete the relevant form(s) in addition to this application form. Please tick which form(s) you are enclosing with this application form (3) Appointing a fund adviser to your International Select Bond or European Select Bond Policy Statement for Old Mutual International Trust Company OR Request for Old Mutual International to appoint a discretionary asset manager Your financial adviser will be able to provide you with the relevant forms. I the trust OLD MUTUAL INTERNATIONAL TRUST COMPANY Old Mutual International Trust Company recommend that you obtain independent legal, tax and other financial advice prior to setting up a trust with Old Mutual International Trust Company and thereafter to keep such advice up to date by periodic review. It is your responsibility to obtain independent advice on the suitability of any trust or service offered by Old Mutual International Trust Company or of the trust assets. Old Mutual International Trust Company do not provide tax or financial advice and do not accept any responsibility or liability for any loss or damage suffered by you as a result of you establishing a trust with Old Mutual International Trust Company or using any of their services. You must comply with all legal and taxation obligations applicable to you under the laws of the jurisdiction in which you are resident/domiciled or any other relevant jurisdiction including, without limitation, the submission of periodic returns to any tax or governmental authority in relation to the trust (if applicable). Purpose of the trust (for example estate planning, tax mitigation) Inheritance tax (IHT) reference of Settlement (if applicable) Your income tax or self assessment reference (continued) 13 of 28

14 I the trust (continued) risk profile Investment objectives The investment objective of the trust is to achieve long-term capital growth. The trust should be managed so that the selected assets represent a diverse portfolio consistent with the investment mandate in section H. FACT FIND Old Mutual International Trust Company Limited will use the information you provide to complete the appropriate UK HM Revenue & Customs (HMRC) forms in relation to your trust. We may require further information and will write to you in the future to obtain this. 1a. Are you UK domiciled or deemed UK domicile? (3) Yes No NOTE Definition of UK domicile can be found on HM Revenue & Customs (HMRC) website: (If the answer is No, please do not complete 3-5 below) 1b. If you answered yes to 1a. what is your country of domicile? (For example England, Scotland, Wales, Northern Ireland) 2. Did you acquire a UK domicile by being born in the UK? (3) Yes No 3. Have you made any previous chargeable lifetime transfers (CLTs) in the last seven years? (3) Yes No NOTE If Yes, please provide details below. Date of transfer Amount of transfer Details of transfer 4. Have you made any previous potentially exempt transfers (PETs) in the last seven years? (3) Yes No NOTE If Yes, please provide details below. Date of transfer Amount of transfer Details of transfer 5. Have you made any other Settlements on the same day as this Settlement or added to another Settlement on the same day as this Settlement? If yes, please confirm the total of all the Settlements made on the same day as this Settlement at the date on which they were set up or Settlements which have been added to on the same day. Yes No Settlement name IHT ref Contributions made 14 of 28

15 J DECLARATION AND APPLICATION NOTE If additional pages are added, each separate page must be initialled by the applicant. Data Privacy Statement Old Mutual International Business Services Limited and Old Mutual International Isle of Man Limited will process information ( Personal Data ) about me and any other party whose Personal Data has been supplied. The processing of Personal Data will take place in a number of jurisdictions. Personal Data will be processed and may be released to other parties within or outside the Old Mutual Group for the following purposes to: Check 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 and corruption or fraud; Allow for the provision of services relating to reinsurance, data hosting, online services, payment or reporting of any tax or levy, or any other services provided to policyholders from time to time; Enable an appointed financial adviser or fund adviser to assist in the provision of services to the policyholder; Compile statistical analysis or market research, where information is not specific to the individual; Comply with any legal obligation which includes the releasing of Personal Data to regulators, law enforcement authorities, tax authorities or other bodies where it is a legal requirement to do so, including the sharing of information under regulations relating to the U.S. Foreign Account Tax Compliance Act and OECD Common Reporting Standards; Enable a discretionary asset manager to assist in the provision of services to Old Mutual International Isle of Man Limited in respect of the assets linked to a policy. Please note that in certain circumstances we may be obliged to share this information with relevant tax authorities. Where Personal Data is released to a third party for the provision of services relating to a policy, the Personal Data will only be used for the purposes for which it is released and will be 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 a copy of an individual s Personal Data will be provided to that individual. Any inaccuracies in an individual s Personal Data records will be rectified. Any questions about Data Privacy should be addressed to the Data Protection Officer, Old Mutual International Isle of Man Limited, King Edward Bay House, King Edward Road, Onchan, Isle of Man, British Isles, IM99 1NU. Warning Please read the declarations on pages 15 and 16 carefully. Any omission or misstatement of a material fact in this application could affect the payment of benefits under the International Select Bond Life or International Select Bond Redemption. 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. You should satisfy yourself that you are able to effect the proposed contract under any taxation, exchange control or insurance law to which you may be subject. DECLARATION BY THE APPLICANT To Old Mutual International A copy of this completed application form is available on request. Old Mutual International Isle of Man Limited will be referred to as Old Mutual International throughout this declaration. 1. I understand and agree that I am applying to enter a new contract with Old Mutual International, it will be subject to the laws of the Isle of Man and the Policy Terms will be in the English language. 2. I request that the Lump Sum referred to as a Premium is invested as I have instructed as an initial premium for policies comprising either an Old Mutual International International Select Bond Life (ref ISBLv1) or an Old Mutual International International Select Bond Redemption (ref ISBRv1), and I request Old Mutual International to issue the policies in my name. 3. I declare to the best of my knowledge and belief that the statements made in this application, and any related documents, are true and complete. I have not concealed a material fact. I agree to provide Old Mutual International with any further information in respect of this application on request. 4. I confirm that Old Mutual International has not provided any investment advice and I, the discretionary asset manager or my fund adviser are responsible for the selection of assets to be linked to my Portfolio Fund. I acknowledge that Old Mutual International and the discretionary asset manager are not responsible for the investment performance of any asset. The provider of the underlying asset is responsible for the management of any assets. 5. I confirm that I am not a resident of the United States of America or any of its territories. If I become resident in the United States of America or any of its territories, Old Mutual International may not be able to accept any further premiums until after I cease to be a resident in the United States of America or any of its territories. 6. I confirm that I have received a copy of the following items and I have had the opportunity to read them before reviewing and signing this application: Key features of your International Select Bond, Details of your Old Mutual International International Select Bond Life (ref ISBLv1) Policy Terms or Details of your Old Mutual International International Select Bond Redemption (ref ISBRv1) Policy Terms, Select Lifestyle Bond product brochure, personal illustration and Explaining your Portfolio Bond fees and charges. Key Information Document (KID) for the International Select Bond Redemption or Key Information Document (KID) for the International Select Bond Life and asset Key Information Document(s) (KIDs) and, where appropriate, the asset Key Investor Information Document(s) (KIIDs). Furthermore, I agree that where I choose to change assets of the portfolio fund in future, I will ensure that I will obtain Fund Key Information Document(s) for those assets before they are purchased. 7. I authorise and request Old Mutual International to effect the facilitation of any initial fee to be taken before my investment is paid into the Policy, if applicable to my application, and I confirm that such payments will discharge Old Mutual International from all liabilities and claims arising from the payment of that initial fee. continued 15 of 28

16 J DECLARATION AND APPLICATION (continued) 8. I understand that in cases where the asset(s) selected is/are not redeemable for a certain period of time, Old Mutual International may not be able to return that part of my payment until the end of that period. The description of the funds and/or assets chosen will give details if this applies. Investments may be made immediately into non daily dealing funds with the understanding that in the event of cancellation or requiring early access that: (a) I may not get my money back immediately and payment may be delayed for some time; (b) the institution may impose penalties and therefore I may get back less than I invested, and/or (c) the only way in which to receive value may be through a transfer of the ownership of that asset into the name of the Policyholder. 9. I appoint the financial adviser to act on my behalf in accordance with the Policy Terms. 10. I confirm that where this application is for an International Select Bond Life, each life assured (or their parent where parental consent is required) consents to this application, and agrees to my acting as their agent for the purpose of the information provided in this application. 11. I consent to my personal data being used in accordance with the Data Privacy Statement. 12. The premium detailed in this application and any other premium tendered in respect of this application are derived solely from the source of funding provided and have, where required, been declared to the relevant tax authority in my country of residence for taxation. 13. The application for an Old Mutual International policy is not being made for the purpose of concealing funds, assets or wealth with a view to the evasion of any taxes I am obliged to pay. 14. I have read and understood the Data Privacy Statement set out above and will make it available to other individuals whose Personal Data has been provided to Old Mutual International either in this application or within accompanying documentation. Advisory Authority Declaration by the applicant (only applicable where you have provided details of the discretionary asset manager who is to act on an advisory basis in section H) 1. I hereby request that Old Mutual International appoint a discretionary asset manager on an advisory basis to provide investment recommendations to Old Mutual International on its assets that are linked to the Portfolio Fund for my Policy. 2. Assuming Old Mutual International appoint the discretionary asset manager shown above to provide recommendations on investments, I hereby understand that the discretionary asset manager appointed on an advisory basis will require agreement to their recommendation before Old Mutual International make an investment decision and I understand that any agreement to the investment recommendation is not legally binding on Old Mutual International. 3. I have agreed with the discretionary asset manager the investment objectives shown or referred to in the Investment Mandate above for the Portfolio Fund for which I will be wholly responsible. 4. I understand that Old Mutual International does place restrictions on the types of investments that may be selected. 5. I acknowledge that where Old Mutual International appoint an advisory discretionary asset manager, a charge will be deducted from the Portfolio Fund. The amount of the charge will be as indicated in this form. 6. I understand that investment decisions are made by Old Mutual International. 7. I understand that the discretionary asset manager appointed on an advisory basis will make a charge to Old Mutual International for the investment recommendations and ongoing suitability monitoring and I am aware of this fee and confirm it is acceptable. DECLARATION BY APPLICANT TO: OLD MUTUAL INTERNATIONAL TRUST COMPANY I confirm that I have read and understood the Old Mutual International Trust Company Limited Client Agreement (Including terms of business, current fee scales and client money information sheet). Please enter the country in which this application form was completed. This application must be completed by the applicant unless you have asked your financial adviser to complete it. Did you complete this application form yourself? (3) If No, did a third party, such as your financial adviser, complete it on your behalf? (3) Yes Yes No No By signing this declaration, you confirm that you have read through the declarations on pages 15 and 16 and, if a third party has completed the application form on your behalf, that all the information provided in it is correct. Signature of applicant Date D D M M Y Y Y Y Copies of the Policy Terms and/or this completed application form are available on request. continued 16 of 28

17 J DECLARATION AND APPLICATION (continued) Advisory Authority Declaration - To be signed by the DISCRETIONARY ASSET MANAGER (only applicable where section H has been completed) I/We accept the appointment by Old Mutual International to provide investment recommendations in respect of Old Mutual International s assets and to submit asset dealing instructions to the relevant Dealing Desk upon the following terms: 1. I/We confirm to Old Mutual International that I/we have the necessary authority and qualifications to make investment recommendations and I/ we have completed these details in the Details of the discretionary asset manager section H on page I/We understand that I/we am/are required to obtain the policyholder s and applicant s agreement to our investment recommendations before submitting the recommendations to Old Mutual International for them to make the investment decision. By submitting an investment recommendation in written form, I/we confirm the policyholder and applicant have agreed to the recommendation. 3. I/We confirm that we will not recommend investments that would: make the policy a personalised portfolio bond in accordance with sections 515 to 526 of the Income Tax (Trading and Other Income) Act 2005 and any successor legislation; be registered in a jurisdiction which is on an OECD, FATF or similar black list ; be realisable less frequently than quarterly; fall within the meaning of section 517 (Policies and Contracts) in the Income Tax (Trading and Other Income) Act 2005 and any successor legislation. 4. I/We understand that I/we should obtain written confirmation of the policyholder s and applicant s agreement to the investment recommendation and this must be retained by me/us. I/We understand that Old Mutual International may request copies of the records at any time. 5. I/We understand that Old Mutual International may terminate this appointment at any time by giving notice to me/the Firm as discretionary asset manager. 6. I/We understand that Old Mutual International have the right to instruct the sale of assets where there is a debit balance on the Transaction Account for the International Select Bond as detailed in the Policy Terms. 7. I/We acknowledge that Old Mutual International will pay us the amount of fee shown in the discretionary asset manager s fees section in this form. 8. I/We agree to indemnify Old Mutual International and its directors, officers and employees against any and all losses paid, suffered or incurred by Old Mutual International or its directors, officers or employees, directly or indirectly arising as a result of the breach of contract, negligence, wilful default or fraud by us or any of our directors, officers or employees in providing the services under this agreement. Name Signature Date D D M M Y Y Y Y Name Signature Date D D M M Y Y Y Y I NEXT STEPS Please send the following supporting documentation with your signed and completed application. Verification of Customer Identity Please note we will not be able to issue your policy until the necessary identification documents have been provided. We require one document from Part A and one from Part B. PART A Individual whose identity is being verified Valid in date Passport National ID card PART B Individual whose residential address is being verified These must be less than three months old A recent utility bill (electricity, gas, water), rates or council tax bill (excluding mobile/ cell phone bills) A bank, mortgage or credit card statement (excluding store cards) An extract from the official register of electors State pension, benefit or other government produced document showing benefit entitlement A recent tax assessment document Proof of ownership or rental of the residential address continued 17 of 28

18 I NEXT STEPS (continued) Document Certification Certification must state I certify this to be a true copy of the original and include the date of certification, the Certifier s full name, signature company name and job title. FURTHER DOCUMENTARY EVIDENCE We may require further documentary evidence in addition to the documents already requested to support your application, particularly in relation to your country of residence and investment amount, before we can process the application. Your financial adviser can establish if further documentary evidence is needed by referring to our Origin of Wealth Guidelines or contacting us before sending in your application form. Please enter what documentary evidence you are enclosing with this application form. (if applicable) J FINANCIAL ADVISER/SUITABLE CERTIFIER DECLARATION DECLARATION BY THE FINANCIAL ADVISER/ SUITABLE CERTIFIER 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 applicant 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 applicant who is of good standing I confirm I will provide further information if required I have not made any changes to the application form after the client has signed it I confirm that the country I gave advice to the applicant in, concerning this investment is: I confirm the date that the advice was given was: D D M M Y Y Y Y Regulatory body authorisation number Regulator name Full name of introducer firm Full name of financial adviser/suitable certifier Old Mutual International financial adviser account number Signature of financial adviser/suitable certifier Date D D M M Y Y Y Y Financial adviser stamp 18 of 28

19 post issue SELECT LIFESTYLE BOND LIFESTYLE TRUST (Isle of Man Discretionary version) This deed can be used where Old Mutual International Trust Company Limited is to be appointed as Trustee. Old Mutual International Trust Company Limited can only be appointed as Trustee where the trust property identified in the First Schedule is an Old Mutual International Isle of Man Limited life assurance or capital redemption policy. All references to Old Mutual International in this form mean Old Mutual International Isle of Man Limited. Please speak to your financial adviser or legal adviser to confirm if this trust deed is suitable to meet your needs. Notes for completion The following notes are referenced throughout this document. Please read them carefully as they will help you complete this document accurately. 1. In submitting this document you are requesting Old Mutual International Trust Company Limited to date the document and bring the Trust into effect on their carrying out a particular act. This is called an escrow and so until that act has been completed no Trust will exist. 2. The Second Schedule is where you complete the details of what policies the Settlor wants to revert and when. Not all policies within the bond have to be listed in the Second Schedule. Any policies not listed will still form part of the Trust Fund but will be held for the benefit of the beneficiaries excluding the settlor. For example, the bond may have 1,000 policies at issue. If the settlor wants 250 of these to revert over a number of years then these should be listed within the Second Schedule. The remaining 750 policies will still form part of the Trust Fund and the trustees can use this for the benefit of the beneficiaries at their discretion. Prior to completing the Second Schedule you should check how many policies your bond has been issued with. 3. Appointment of a Protector is not essential but if a non-uk resident Trustee is to be appointed then some Settlors may feel more comfortable knowing that Trustee dispositive functions will require the consent of another party appointed to oversee the carrying out of those functions. That party must consent to the appointment and so will be required to sign the document. 4. This is the name the Settlor gives to the Settlement. For example, The Mary Jones Settlement 2016 where Mary Jones is the Settlor. To ensure that you do not fall within the gift with reservation rules (Para 7, Schedule 20, Finance Act 1986), it is essential that you provide funds from your own bank account. Funds should not come from a joint bank account. As the Lifestyle Trust is a Single Settlor Trust, the spouse or civil partner of the Settlor may have set up a Lifestyle Trust at the same time. Where this is the case it should be considered whether the spouse or civil partner of the Settlor should be removed as a potential Beneficiary of the Trust to ensure there are no inheritance tax implications under reciprocal arrangement anti-avoidance legislation. This can be achieved by crossing out spouses from the definition of beneficiary in section 2. Such an amendment to the deed should be initialled by all parties to the deed. Identifying the parties In order for Old Mutual International to comply with the anti-money laundering legislation and countering terrorist financing legislation and guidelines of the Isle of Man, it will be necessary for proof of the identity and address of the Settlor, and any Protector to be established. In addition, any persons who are likely to benefit from the Trust Property should also be identified in the same manner. 19 of 28

20 post issue SELECT LIFESTYLE BOND LIFESTYLE TRUST (Isle of Man Law Discretionary version) This draft document is provided strictly as a draft for consideration by the Settlor s legal advisers. Old Mutual International accepts no responsibility for any loss of whatsoever nature occasioned by the adoption unamended or otherwise of this draft trust document. Any advice given on completion of the Lifestyle Trust is accordingly given on the basis that, having discussed the trust terms with legal advisers, the draft trust put forward for consideration is adopted duly completed but otherwise unamended. All references to Old Mutual International in this document mean Old Mutual International Isle of Man Limited. 1 Lifestyle Trust As the Original Trustees are Old Mutual International Trust Company Limited and the Trust Property is an Old Mutual International policy, the Settlor authorises the Original Trustees to date this deed on the date that its common seal is affixed. This Settlement is made the day of 2 0 ( the Declaration Date ) See Note 1 regarding date. between (The Settlor) Address ( the Settlor ) of the one part and Address Old Mutual International Trust Company Limited King Edward Bay House King Edward Road Onchan, Isle of Man, IM99 3DJ, British Isles ( the Original Trustees ) of the other part. Now this Deed witnesses as follows: A. The Settlor assigns the property specified in the First Schedule below to the Original Trustees to hold on the following terms. B. This Settlement shall be known as See note of 28

21 2 Definitions (1) The Trustees means the Original Trustees or the Trustees of this Settlement for the time being. (2) The Trust Fund means: (i) the property specified in the First Schedule below: (ii) all money investments or other property paid or transferred by any person to the Trustees or placed under the control of the Trustees and (in either case) accepted by the Trustees as additions to the Trust Property under Clause 3 below; and (iii) all property from time to time representing the above. (3) Trust Property means any property comprised in the Trust Fund. (4) The Trust Period means the period of 150 years beginning on the Declaration Date. (5) The Beneficiaries means (i) the children, step children and descendants of the Settlor; (ii) the spouses, former spouses, widows, widowers, civil partners, former civil partners and surviving civil partners of the Settlor or any persons in (i) above; (iii) any nieces or nephews of the Settlor; (iv) the brothers or sisters of the Settlor; (v) the persons named or added under clause 4 below; (vi) the persons or objects named in the following box (if any): at any time during which there are no Beneficiaries under any of (i) to (vi) above, any company, body or trust established for charitable purposes only; Provided that no Excluded Person shall in any circumstances be or become a member of the class of Beneficiaries; and Beneficiary shall be construed accordingly. (6) Excluded Persons means the Settlor and any person who shall have previously added property to the Trust Fund; and Excluded Person means any one of the Excluded Persons. (7) Protector means the person (if any) shown in the Third Schedule below, or such other person as is the Protector for the time being. (8) civil partner has the meaning given to it in the Civil Partnership Act 2011 (or any replacement legislation). (9) Date of Entitlement means the anniversary of the start date of the Policies comprised in a Policy Fund occurring in the year specified in the table in the Second Schedule as the Year of Entitlement of that Policy Fund. (10) Policies means all of the policies of life assurance or capital redemption specified in the Second Schedule; and Policy means one of the Policies. (11) Policy Fund means the Policy(ies) designated to that fund in the Second Schedule the full benefit thereof (whether by surrender assignment or otherwise) and the proceeds thereof and all property from time to time representing the same together with any accumulations of income arising and all property from time to time representing the same and each Policy Fund shall be known by the one or more letters assigned to it in the Second Schedule. (12) Settlor Consent means during the life of the Settlor the written consent of the Settlor. (13) Vesting Date means in relation to a Policy Fund the date which is the Date of Entitlement of that Policy Fund or such later date within the Trust Period (not being a date earlier than the date which is for the time being the Vesting Date) as the Settlor during his life may from time to time before the date which is the Vesting Date for the time being specify in writing to the Trustees. (14) Vesting Event means the survival by the Settlor to the appropriate Vesting Date. (15) Unless the context otherwise requires, a reference to any gender includes a reference to the other genders and the singular includes the plural and vice versa. 3 POWER TO RECEIVE ADDITIONAL PROPERTY The Trustees may, during the Trust Period, accept additional money, investments or other property, of whatever nature and wherever situate, paid or transferred to them by any other person. Such additional money, investments or other property shall, subject to any contrary direction, be held upon the trusts and subject to the powers and provisions of this deed. 4 Power of addition and exclusion of Beneficiaries (1) The Settlor during his lifetime, or two Beneficiaries after the death of the Settlor, may by deed or deeds and with the written consent of the Trustees at any time or during the Trust Period add any persons to the Beneficiaries provided that no Excluded Person may be added to the Beneficiaries. (2) Any Beneficiary or any person who may become a Beneficiary may declare in writing to the Trustees that he is to cease to be a Beneficiary, or may not be added as or become a Beneficiary, to take effect from the date of receipt of such declaration. 5 TRUST INCOME Subject to the overriding powers in clause 6A and to clause 6B below: (1) The Trustees may accumulate the whole or part of the income of the Trust Fund during the Trust Period. That income shall be added to the Trust Fund. (2) The Trustees shall, subject to the prior written consent of the Protector (if any), pay or apply the remainder of the income of the Trust Fund to or for the benefit of any of the Beneficiaries, as the Trustees think fit, during the Trust Period. 21 of 28

22 6a Overriding powers in relation to the trust Fund The Trustees shall during the Trust Period have the following powers exercisable with the written consent of the Protector (if any): (1) Power of appointment (a) The Trustees may appoint that they shall hold the whole or any part or parts of the Trust Fund for the benefit of all or any one or more of the Beneficiaries, on such terms as the Trustees think fit. (b) An appointment may create any provisions and in particular: (i) discretionary trusts and (ii) dispositive or administrative powers, exercisable by any person. (c) An appointment shall be made by deed and may be revocable during the Trust Period or irrevocable. (d) The power of appointment shall not be exercisable in respect of a Policy Fund on or after the occurrence of a Vesting Event in relation to that Policy Fund. (2) Transfer of Trust Property to new Settlement: Where the Settlor has died, the Trustees may by deed declare that they hold any Trust Property on trust to transfer it to the Trustees of a Qualifying Settlement, to hold on the terms of that Qualifying Settlement, freed and released from the terms of this Settlement. A Qualifying Settlement here means any settlement, wherever established, under which every person who may benefit is (or would if living or added be) a Beneficiary of this Settlement. (3) Power of advancement: The Trustees may pay or apply any Trust Property for the advancement or benefit of any Beneficiary. 6B Settlor s Reversionary Interest Subject to any appointment made in accordance with clause 6A where a Vesting Event occurs in relation to a Policy Fund, the Trustees shall from the Vesting Date hold that Policy Fund and its income for the Settlor absolutely. 7 Default Trusts Subject as above, the Trust Fund and its income shall be held on trust for the descendants of the Settlor living at the end of the Trust Period (and in equal shares if more than one) absolutely and, subject to that for such charitable purposes as the Trustees shall select. 8 Successor Protectors and tacit consent (1) The Protector shall cease to be the protector: (i) if an individual, on death; or (ii) if a corporation, on dissolution; or (iii) in either case, on; - becoming unable or unfit to act; or - making a valid appointment under (2) below. (2) If the Protector wishes to retire he may appoint in writing another person to be Protector of this Settlement and (i) when the Trustees have been given written notice of the appointment; and (ii) the person appointed has consented in writing; then such person shall immediately become the Protector in place of the retiring Protector and any nomination under (3) below shall be revoked. (3) The Protector may in writing nominate a person to succeed him should he cease to be the Protector and, upon such cessation, (i) if the nomination remains unrevoked; (ii) the Trustees have been given written notice of the nomination; and (iii) the person nominated consents in writing; then such person shall immediately become the Protector. (4) Where there is a Protector but he fails to respond to a written request from the Trustees within 30 days (or such longer period as may be specified under a notice given to the Trustees under subclause 9(3) below), then the Trustees may take silence to indicate written consent by the Protector and act accordingly. (5) If, despite the provisions of this clause, there ceases to be at any time a Protector of this Settlement, then the Settlor, or if there is no Settlor in existence and capable of making an appointment, the Trustees may in writing appoint any person (other than a Trustee) to be the Protector. (6) There shall be no duty to appoint a Protector, whether or not the Settlor has appointed a Protector by this Deed. 9 Powers and duties of the Protector (1) The powers and duties of the Protector are fiduciary in nature. (2) The Protector is under no duty to enquire into or interfere with the management or conduct of this Settlement, unless he has actual knowledge of circumstances which call for enquiry. (3) The Protector shall consider the appropriateness of any act before giving his consent to it and shall if need be inform the Trustees that the 30 day period mentioned in clause 8(4) is insufficient in the circumstances and inform them of such specified longer period as he may reasonably require. 22 of 28