For financial adviser use Powered by Wealth Interactive Data capture This form is for financial advisers to gather the necessary information from a client to input new business online for the Collective Investment Bond (CIB), Collective Investment Plan (CIP), Collective Redemption Bond (CRB), Executive Investment Account (EIA), Executive Investment Bond (EIB), Executive Investment Plan (EIP), Executive Redemption Bond (ERB), Investment Account (IA) and Wealth Management Plan (WMP) on Wealth Interactive. NOTE Please check with the regional office for the products available in the relevant jurisdiction. This form is not an application form and will not be accepted as such if sent to us. You must submit this information online. Mandatory information is denoted by *. If any of this information is missing, you will not be able to complete the online process. Items preceded by # denote information that is dependent on the options that have been selected and will not be required in all cases. There are two stages on Wealth Interactive: Section A Creating a new client Section B Creating a new investment (opening an account) Section A INFORMATION REQUIRED TO CREATE A NEW CLIENT If there are any further applicants please photocopy section A 1 Details of applicant *Nationality Dual Nationality (if any) *Country of residence * Correspondence language *Assigned adviser * Product Company Old Mutual International Isle of Man Limited/Old Mutual International Isle of Man Limited Singapore Branch *Title (3) Mr Mrs Miss Other *Full forename(s) *Surname Middle name Previous name or alias (if any) *Gender (3) Male Female *Country of birth * National Registration Identity Card (NRIC) (Applicable for Singapore only) 2 Address and contact details *Residential address * Date of birth (dd/mm/yyyy) * Town/City of birth D D M M Y Y Y Y Post Code 1 of 8
PROFESSIONAL INVESTOR (PI) STATUS (Applicable to Hong Kong (HK) only) # If this is HK relevant business, please indicate client status: n PI PI (CIP and EIP applicants must have PI status) Correspondence address New correspondence address * Same as residential address * Care of adviser *New correspondence address (# Full address plus postcode and country required) Post Code Client s contact details (please ensure you provide the country dial code) *Telephone number ( +44 00 000 0) # Mobile number (must fill in for Singapore) ( +44 00 000 ) # Fax number ( +44 00 000 0) *Email address Identification details *ID type (Where applicable for Hong Kong - For applicants who are Hong Kong permanent residents, please provide the Hong Kong identity card details as a minimum requirement. For applicants who are not Hong Kong permanent residents, please provide the Hong Kong identity card/passport details as appropriate.) *ID number *ID country of issue * ID expiry date (only if passport used) D D M M Y Y Y Y 3 EMPLOYMENT details * Please indicate the client s employment status. Employment status #Where your client is employed, self employed or retired, please note: Occupation Employer s name Employer s address (full address) Employed Self employed Retired t employed Country Post Code Employer web address Phone number ( +44 00 000 00 ) Fax number ( +44 00 000 00 ) Email address Salary information * Annual salary or last known salary: # Bonus (if any) Currency Currency Amount Amount 4 taxation details * Country of residence for taxation *Tax reference number # Resident for taxation in more than one country (please provide the additional information in the above boxes) 2 of 8
Section B Create new investment (opening an account) *Ownership type (choose from) Single applicant Joint applicant Single trustee applicant Joint trustee applicant Corporate applicant Corporate trust applicant Policy preferences #Lead Policyholder (for a joint policy, please indicate the lead policyholder s name) *Assigned adviser *Product *Policy currency Custodians (t applicable to WMP) # Please select either one from the option below: Assets held by the default custodian for Old Mutual International One authorised custodian to hold assets (Please complete Old Mutual International to appoint an authorised custodian form) 1 premium details *Premium type Lump sum Lump sum amount Charging package *Charging structure code And/Or Asset transfer amount (please note if you are doing an Asset Transfer you will need to complete an Asset Transfer form. This is available on request.) (please note that there are new charging structure codes that should be used. If you do not already have the new matrix of codes, this is available on request.) Please select the Establishment Charge Period (Applicable to WMP only) 1 year 2 year 3 year 4 year # If you have been granted permissions to amend initial commission, please enter the % that you wish to waive, otherwise the charging structure default will be used: % * Ongoing service charge % (t applicable for Hong Kong) 2 and 3 select assets and buy amounts # Skip this step? You can skip this step and the money will be placed in the Transaction Account for investing at a later date: You will be able to select from published portfolio: # Portfolio name Or # List of assets (for WMP must be SFC approved Tier 1 assets) Asset name ISIN % of contribution Unit/Amount 3 of 8
4 application details *Country of advice *Is this a replacement Policy (Applicable to Singapore only) * Number of policies (default will be 12) * Correspondence Address (if different from policyholder(s) address.) Post Code Applicant 1 Applicant 2 Care of Adviser REPLACEMENT OF LIFE POLICIES (Applicable to Hong Kong only) * Has your client replaced in the last 12 months, any or substantial part of their existing life insurance policy(ies) with this proposal? * Does your client intend to replace in the next 12 months any substantial part of their existing policy(ies) with the proposal? If has been selected, Customer Protection Declaration form is required. fund/investment adviser appointment The fund/investment adviser has to hold relevant authorisation in offering the discretionary service or non-discretionary advice. *Is the assigned adviser also the fund/investment adviser? If is selected, an appointment of fund adviser form is required to be signed and uploaded. What is the basis of the fund/investment advice? Discretionary You will be able to enter a fund adviser payment fixed amount regular withdrawals n-discretionary *Regular Withdrawal te: for the Wealth Management Plan, regular withdrawals should be set up only if no regular premium arrangement is in place. #Withdrawal Type Withdrawal currency or % per annum, based on Plan value at end of previous quarter Percentage % per annum of premium invested OR Fixed annual amount Description Income Trustee Fees Frequency: Annually Monthly Half-yearly Quarterly Please state the start date for monthly withdrawal # Withdrawn from (*) Transaction Account: OR # Specify the nominated asset: (only available if section 2 has been completed) Asset Name Asset name D D M M Y Y Y Y % of each asset for regular withdrawal 4 of 8
regular withdrawals (continued) Enter banking details for regular withdrawal payments: #Bank Details Swift Code/ BIC Code/ UK Sort Code IBAN Currency Account number Account held for years months Remittance details Lives assured (For ERB and CRB, this section is not required) * Is the policyholder(s) the life assured?: If, please indicate who is the life assured : Policyholder 1 Policyholder 2 # If, please detail name and address of the additional life(s) assured. If there is more than one additional life assured, we will need the same information for each person. # Title # Full forename(s) # Surname # Relationship to first applicant Spouse Child Financial dependent Other # Date of birth (dd/mm/yyyy) D D M M Y Y Y Y # Gender (3) Male Female # Residential address, including postcode and country: Postcode # Nationality 5 of 8
5 PAYMENT DETAILS AND ORIGIN OF WEALTH INFORMATION Payment method Bank details * please choose one from: Cheque Bank Transfer *Currency *Amount *Account Name # UK Sort code # IBAN # SWIFT or BIC Code *Account number Bank State Branch (BSB) Account held for years months Remittance details Origin of wealth You will have to state the source and value of any of the following origins of wealth: proceeds of compensation, competition or gambling win, gift, inheritance, investments/accumulated earned income, loan, maturing investments/policy claim/replacement policy, other unearned income, sale of interest in company, sale of property, sale of shares. If the money is coming from accumulated earned income you will need to provide the name and address of employer, occupation, details of annual salary, bonuses and fees and details of the account where the earned income was accumulated. Additional information may be required depending on the source. * Where did the money come from? * Date the money was received *Total amount The total contribution can be made up from a number of origin of wealth sources. You may need to upload the scanned image (OR copy) of the certified true copy of originals of proofs of the origin of wealth - this is dependent on the source. 6 Data Privacy information You are about to provide personal details of your client. You should make them aware that you are doing this, and make them aware of our Privacy Policy, which explains why we collect their data and how we use it. The Privacy Policy can be found at oldmutualinternational.com/privacy on our website. 6 of 8
7 declare and upload Suitability Declaration (based on client s answer in the Important facts statement applicable to Hong Kong only) A B DOCUMENT UPLOAD CHECKLIST You will need to upload a scanned image (OR copy) of the certified true copy of the original (applicable to HK) and the following forms. For Hong Kong Proof of identification Proof of residential address Important Facts Statement and Replacement Declaration (Original copy to be sent to OMI) Customer Protection Declaration (if replacing a life policy) Signed personalised illustration PI Declaration (applicable to CIP and EIP only) Financial Needs Analysis and Risk Profile Questionnaire (the agreed template/pack as cleared by us) Affordability Declaration (if any applicant is aged 60 or above) Appointment of fund adviser form (if applicable) Charging Structure (applicable to EIP and CIP only) Taxation document (if applicable) For Singapore Proof of identification Proof of residential address Appointment of fund adviser form (if applicable) For others Proof of identification Proof of residential address Appointment of fund adviser form (if applicable) Charging Structure (if applicable) Taxation document (if applicable) APPLICANTS (Applicable to Singapore only) Applicant 1 Applicant 2 (if any) Name Ordinarily resident t ordinarily resident Evidence t ordinarily resident evidence t ordinarily resident Singapore citizen Ordinarily resident t ordinarily resident Evidence t ordinarily resident evidence t ordinarily resident Singapore citizen Applicant 3 (if any) Applicant 4 (if any) Name Ordinarily resident t ordinarily resident Evidence t ordinarily resident evidence t ordinarily resident Singapore citizen Ordinarily resident t ordinarily resident Evidence t ordinarily resident evidence t ordinarily resident Singapore citizen APPLICANT ACCREDITED INVESTOR DECLARATION (Applicable to Singapore only) # Is the applicant an Accredited Investor? 7 of 8
www.oldmutualinternational.com www.oldmutualinternational.com/hk 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)1624 655 555 Fax: +44 (0)1624 611 715. Licensed by the Isle of Man Financial Services Authority. Old Mutual International Isle of Man Limited is a member of the Association of International Life Offices. 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 is the registered business name of Old Mutual International Isle of Man Limited Singapore Branch. Old Mutual International Isle of Man Limited Singapore Branch, 50 Collyer Quay, OUE Bayfront, #05-07, Singapore, 049321. Phone: +65 6216 7990 Fax: +65 6216 7999. Registered in Singapore Number T08FC7158E. Authorised by the Monetary Authority of Singapore to conduct life assurance business in Singapore. Member of the Life Insurance Association of Singapore. Member of the Singapore Finance Dispute Resolution Scheme. Old Mutual International s Hong Kong office: 24th Floor, Henley Building, 5 Queen s Road Central, Hong Kong. Phone: +852 3552 5888 Fax: +852 3552 5889. E-mail: askhk@ominternational.com Authorised by the Insurance Authority of Hong Kong to carry on long term business. 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)1624 655 555 Fax: +44 (0)1624 611 715. Licensed by the Isle of Man Financial Services Authority. Old Mutual International Isle of Man Limited is a member of the Association of International Life Offices. Old Mutual International is registered in the Isle of Man as a business name of Old Mutual International Isle of Man Limited. PDF13900/INT18-1382/July 2018