OR EUROPEAN SELECT BOND

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1 Fund adviser details Old Mutual International/ Old Mutual International Ireland account number Name of fund adviser APPOINTING A Telephone number FUND ADVISER Fax number TO YOUR address International OR EUROPEAN SELECT BOND Only for use in the UK Company name Address This document was last updated in August Please confirm with your financial adviser that this is the most up-to-date document for your product or servicing needs. This form is only for use when appointing fund advisers registered in the United Kingdom. Please use only blue or black ink and CAPITAL LETTERS. All references to Old Mutual International in this form mean Old Mutual International Isle of Man Limited, who are the providers of the International Select Bond. All references to Old Mutual International Ireland in this form mean Old Mutual International Ireland dac, who are the providers of the European Select Bond. You should use this form to appoint a fund adviser to an Old Mutual International - International Select Bond or Old Mutual International Ireland European Select Bond and authorise Old Mutual International or Old Mutual International Ireland to pay the fees that you have agreed with your fund adviser from your policy. The form must be completed by both the applicant(s), or the policyholder(s) where the policy has already started, and the fund adviser. Each must check that this form is completed correctly and then sign to authorise the payment. Any errors or omissions may delay the implementation of your instructions. Where applicable, we will send the lead policyholder confirmation of the fee we have set up. These details should be checked to ensure the fund adviser fee payment details are correct. If the details are incorrect, the lead policyholder should contact Old Mutual International or Old Mutual International Ireland immediately using the contact details provided. More information about fees and how they are deducted from your policy can be found in our Explaining your Portfolio Bond fees and charges. Please ask your financial adviser for a copy. Please note if you have appointed more than one fund adviser for your policy, you will need to complete a separate appointment form for each fund adviser. Please note we must receive this appointment form at our Head Office by post or courier, in line with the policy terms. 1 CUSTOMER AGREEMENT FOR COMPLETION BY THE APPLICANT(S) OR POLICYHOLDER(S) of first or sole applicant/policyholder of second applicant/policyholder Please enter either the applicant s Old Mutual International or Old Mutual International Ireland Customer ID Number, where the policy has not started, or the policy number where it has started. If you do not know your Customer ID Number, please ask your financial adviser. Product Provider for policy: Old Mutual International Old Mutual International Ireland (please tick as appropriate) Customer ID no. of first or sole applicant Customer ID no. of second applicant Or policy number continued 1 of 6

2 1 CUSTOMER AGREEMENT FOR COMPLETION BY THE APPLICANT(S) OR POLICYHOLDER(S) (CONTINUED) APPOINTMENT OF FUND ADVISER Declaration made by each of the applicants/policyholders, and where Trustees are the applicants/policyholders, the declaration is made jointly by all trustees and where a Company is the applicant/policyholder, the declaration is made by the authorised signatories on behalf of the Company. The following appointment should be construed to mean the relevant Product Provider applying to your policy. I/We confirm that I/we am/are legally entitled to effect any of the policy options contained in the Policy Terms. Assets in the Portfolio Fund linked to my policy that are relevant to this appointment: all assets held in the Portfolio Fund linked to my policy assets held by our default custodian I/We appoint and authorise the fund adviser detailed on page 1 to act in the following capacity (tick one option only) Option 1 Non-Discretionary Authority I/We understand that the fund adviser will discuss any proposed alterations to the asset composition of the relevant assets for my/our policy as detailed above with me/us and that they must have my/our written agreement to any changes before they request these on my/our behalf. Option 2 Discretionary Authority I/We understand that the fund adviser has complete discretionary authority, without consulting me/us, to make all investment decisions for the relevant assets for the policy to buy or sell assets, hold a credit balance or other assets. I/We authorise Old Mutual International/Old Mutual International Ireland to act upon the asset dealing instructions of the fund adviser. I/We appoint the fund adviser, as detailed in this appointment form, to act on my/our behalf in respect of the policy. I understand that the fund adviser is not acting on behalf of Old Mutual International/Old Mutual International Ireland. Where we are Trustees and Option 2 is selected, the provisions of the trust allow us to delegate investment decisions to the fund adviser. Where the policyholder is a Company and Option 2 is selected, I/we as authorised signatory(ies) of the Company confirm that the articles of association for the Company allow investment decisions to be delegated to the fund adviser. I/We understand that Old Mutual International/Old Mutual International Ireland may need to: (a) confirm that the fund adviser is regulated by an appropriate regulatory authority; and (b) check that the fund adviser has the qualifications required by law or by regulation for the activity to be carried out. I/We acknowledge and agree that such confirmation is to enable Old Mutual International to comply with its regulatory duties as an authorised insurer in the Isle of Man or Old Mutual International Ireland to comply with its regulatory duties as an authorised insurer in Ireland. I/We understand that this is not, and should not be construed as, any endorsement of the fund adviser and that Old Mutual International/Old Mutual International Ireland do not warrant the fund adviser s suitability or regulatory credentials. I/We agree that Old Mutual International/Old Mutual International Ireland is not responsible for any loss or liability to the policy arising from this appointment. I/We confirm that I/we understand that if Old Mutual International/Old Mutual International Ireland becomes aware that a fund adviser: (a) has been refused membership by, or has been expelled from, a professional organisation; or (b) is under investigation by, or has been the subject of disciplinary action by a regulatory authority; or (c) has or is carrying out activities in a manner which could prejudice or be harmful to Old Mutual International/Old Mutual International Ireland s reputation; then Old Mutual International/Old Mutual International Ireland reserves the right to cease to act on the instructions of the fund adviser, with immediate effect and Old Mutual International/Old Mutual International Ireland will inform me/us of the fact. I/We understand I/we must notify Old Mutual International/Old Mutual International Ireland in writing of any changes which affect this appointment, or the authority of the fund adviser. I/We understand that Old Mutual International/Old Mutual International Ireland will continue to accept instructions from the fund adviser, unless and until I/we advise Old Mutual International/Old Mutual International Ireland of a change to this appointment or you receive instructions confirming changes from the fund adviser. I/We understand that I/we can terminate the appointment of the fund adviser by giving notice in writing to the fund adviser and to Old Mutual International/Old Mutual International Ireland, at Old Mutual International s Head Office/Old Mutual International Ireland s Head Office, of the termination of this appointment. The termination will not affect any transactions already carried out or for which binding instructions have been given directly, or indirectly. Where I/we have chosen Non-Discretionary Authority: (a) I/We understand that all decisions in relation to the investment strategy and alterations to the asset composition of the relevant assets in the Portfolio Fund linked to the policy remain my/our sole responsibility. (b) I/We have agreed with the fund adviser that they must: (i) discuss any proposed alterations to the asset composition with me/us; and (ii) have my/our prior written agreement before any changes are made. 2 of 6 continued

3 1 CUSTOMER AGREEMENT FOR COMPLETION BY THE APPLICANT(S) OR POLICYHOLDER(S) (CONTINUED) Where I/we have chosen Discretionary Authority: (a) (b) I/We understand that the fund adviser has complete discretionary authority, without consulting me/us, to make all investment decisions for the relevant assets for the policy to buy or sell assets, hold cash or other assets. I/We authorise the fund adviser to exercise on my/our behalf any of the options available under the Policy Terms applicable to the policy relating to buying and selling assets and/or changing my/our assets for the relevant assets for the policy; I/We confirm I/we have delegated all investment decision-making for the relevant assets for the policy to the fund adviser. In respect of a fund adviser fee, if requested in this appointment form, I/we authorise and request Old Mutual International/Old Mutual International Ireland to effect the Regular Withdrawals for ongoing fees to facilitate fund adviser fees that I/we have agreed to pay to the fund adviser and my/our financial adviser has explained the tax implications of facilitating fund adviser fees from the policy. Fund adviser s fee Please enter the fee that you have agreed will be deducted from the policy. Tick the No ongoing fund adviser fee payable box where Old Mutual International/Old Mutual International Ireland is not to pay fees to your fund adviser from the policy. Fee shown below applies (please tick as appropriate): equally to all assets in the Portfolio Fund linked to the policy (fee must be a percentage). to assets in the Portfolio Fund linked to the policy held by the default custodian. Please note Fees can be paid as a monetary amount or as a percentage of the value of the assets in the Portfolio Fund held by the default custodian for which they are appointed as fund adviser each year. Fund adviser fees are paid quarterly by a regular withdrawal from the policy. Percentage fees will be calculated using the portfolio fund value at the quarterly date. Your fund adviser can explain how this is calculated. A monetary amount must be a whole amount, inclusive of VAT. We will continue to pay the fee until instructed by you to change the amount. This means that if you are paying a percentage fee, the amount paid to your fund adviser may increase if you make a top up, or decrease if you make a withdrawal. The fund adviser fee must be paid in the policy currency. Fees are payable to fund advisers only. If a Discretionary Asset Manager has been appointed then no fees should be requested in this form. Please enter the policy currency (3) US$ E Please enter the fund adviser fee amount you authorise us to pay your fund adviser each year. each year or. % each year No ongoing fund adviser fee payable (3) DEALING ADVICE FEE (Only applicable to assets held with our default custodian) The dealing advice fee is a percentage of the value of assets on the purchase date of a qualifying transaction. Please refer to the Policy Terms for the list of excluded transactions. The dealing advice fee will be payable to your fund adviser on the next quarterly date following the purchase date of the qualifying transaction. The fee must be inclusive of VAT. Please enter the dealing advice fee percentage you authorise us to pay your fund adviser % of the value of assets on the purchase date of a qualifying transaction. Please note that both regular withdrawals and part surrenders count towards the 5% per annum tax deferred withdrawal allowance under current HM Revenue & Customs chargeable event rules. I/We agree that such fees shall be payable directly to the fund adviser by Old Mutual International/Old Mutual International Ireland on receipt by Old Mutual International/Old Mutual International Ireland of this authority, which hereby authorises Old Mutual International/Old Mutual International Ireland to debit the policy with an equivalent amount which will be paid quarterly at each valuation date. continued 3 of 6

4 1 CUSTOMER AGREEMENT FOR COMPLETION BY THE APPLICANT(S) OR POLICYHOLDER(S) (CONTINUED) Such fees will be treated as regular withdrawals from the policy. If you are investing in the WEALTHSELECT investment range, your regular withdrawals will be funded by proportionate sale across all assets. If you are investing in the SELFSELECT investment range, please select one of the following options: Proportionate sale across all assets Sale of specific nominated asset(s) If you have chosen the sale of specific nominated asset(s), please state which specific asset(s) is/are to be used. Please note that if you have previously selected to phase your investment, the asset(s) you specify here cannot include the Feeder Fund. For further information on fees and how they are deducted from the policy please refer to the brochure Explaining your Portfolio Bond fees and charges. Please ask your Financial Adviser for a copy. It is agreed that all assets are held in the name of Old Mutual International/Old Mutual International Ireland and all trades must be done in the name of Old Mutual International/Old Mutual International Ireland. Signature of applicant(s)/policyholder(s) (if more than one applicant/policyholder, all must sign) Signature of first or sole Signature of second Signature of third Signature of fourth 2 ACCEPTANCE OF APPOINTMENT FOR COMPLETION BY THE FUND ADVISER PAYMENT DETAILS FOR FUND ADVISER FEE Do not complete this section if Old Mutual International/Old Mutual International Ireland already holds the information requested. Please note, fund adviser fees are paid in the policy currency. Payment of fees will be approximately 6-8 weeks after the quarter end. Payment method (3) Electronic bank transfer 1 BACS 2 1 Bank charges will be applicable for electronic bank transfers, for example telegraphic transfer payments. 2 BACS is only available for sterling payments to a UK bank. Bank account holder (name as stated on bank account) Bank account number/iban Sort code (if applicable) SWIFT or BIC code (if applicable) Bank name Bank address 4 of 6 Postcode Country

5 2 ACCEPTANCE OF APPOINTMENT FOR COMPLETION BY THE FUND ADVISER (CONTINUED) BASIS ON WHICH THIS AUTHORITY IS GIVEN (3) TICK ONE OPTION ONLY Non-Discretionary Authority (Option 1 selected). I understand that I must obtain the written agreement of the applicant(s)/policyholder(s) to any investment advice given and that I may be asked to provide evidence of such to Old Mutual International/Old Mutual International Ireland if requested. Discretionary Authority (Option 2 selected). I confirm that my firm is authorised by the Financial Conduct Authority (FCA) to carry out the regulated activity of managing investments. This authority enables me to provide investment instructions to Old Mutual International/Old Mutual International Ireland and I confirm that I have the agreement of the applicant(s)/policyholder(s) to issue asset dealing instructions on their behalf. Please refer to the Policy Terms for further information on paying fees to the fund adviser. My FCA licence number is (only applicable if option 2 has been selected above) Telephone number address I have read the conditions listed in this form and agree to act in accordance with them. I confirm I will notify you of any changes to my authority. Signature of fund adviser of signatory Position uplease provide us with an authorised signatory list, including signing powers, for your company, showing all individuals authorised to place instructions with us on behalf of your company. In the absence of a signatory list we will assume the only authorised individual is the signatory on this form. The fund adviser who has signed above is the fund adviser to be appointed. Signature of applicant(s)/policyholder(s) (if more than one applicant/policyholder, all must sign) Signature of first or sole Signature of second Signature of third Signature of fourth 5 of 6

6 Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Old Mutual International Isle of Man Limited is registered in the Isle of Man under number 24916C. Registered and Head Office: King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0) Fax: +44 (0) Licensed by the Isle of Man Financial Services Authority. Old Mutual International is registered in the Isle of Man as a business name of Old Mutual International Isle of Man Limited. Old Mutual International Ireland dac is regulated by the Central Bank of Ireland. Registered No Administration Centre for correspondence: King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU. Tel: +353(0) Fax: +353(0) Registered and Head Office address: Hambleden House, Lower Pembroke Street, Dublin 2, Ireland. VAT number for Old Mutual International Ireland dac is S. Old Mutual International is registered in Ireland as a business name of Old Mutual International Ireland dac. PDF13419/INT /August of 6