Financial adviser stamp Amending your Personal Pension/ Personal Retirement Account change of status and reinstatement Please enter your business postcode Agency reference number *PPPPEN01* Please use BLOCK CAPITALS only and blue or black ink. Please complete all relevant sections. If any relevant sections are incomplete, we will write to you and ask you for the missing information, which may delay your application. All references to Old Mutual Wealth in this application mean Old Mutual Wealth Life Assurance Limited. Date all changes are to be effective from 0 1 M M 2 0 Y Y All increases must be with effect from the first of the month. A Member s personal details and eligibility PLEASE COMPLETE PARTS 1 AND 3 IF YOU ARE: 16 OR OVER AND IN EMPLOYMENT, OR 18 OR OVER PARTS 1, 2 AND 3 MUST BE COMPLETED BY YOUR LEGAL GUARDIAN IF YOU ARE: UNDER 16, OR BETWEEN 16 AND 18 AND NOT IN EMPLOYMENT Part 1 Member s details Member Plan/Account number Permanent residential address. If changed. (Please note that c/o addresses are not acceptable. Include postcode where the address is in the UK.) Telephone number E-mail address National Insurance number (if over 16) Are you currently a UK resident? Yes No If No, please state the tax year in which you stopped being a UK resident, eg 2009/2010. Are you a Crown employee based overseas, or the spouse/civil partner* of one? Yes No * As defined by the Civil Partnership Act 2004. continued
A Member s personal details and eligibility (continued) Part 2 Legal guardian s details Title (3) Mr Mrs Miss Other Full forename(s) Surname Permanent residential address (Please note that c/o addresses are not acceptable. Include the postcode where the address is in the UK.) Telephone number E-mail address Part 3 Member s status Employed 3 You are liable to tax on earned income from your employment for the income tax year of assessment. Pension Income You already have a pension income for which you are liable to tax for the income year of assessment. Self-employed Chargeable to tax for the income tax year of assessment concerned in respect of annual profits or gains arising or accruing from any trade, profession or vocation carried out by you. Child under 16 Caring for one or more children aged under 16 Caring for a person aged 16 or over Full-time education Unemployed Other (please specify) B Confirmation of earnings My earnings chargeable to UK income tax for the current year are If you are employed, please provide your employer s details in the boxes below. Employer s name Address If you have employer contributions, or if your employer is acting as a co-ordinator for the payment of contributions, your employer must complete section G as well. 2
C Personal Contributions Regular contribution Gross Net* Personal (payable net of basic rate income tax) Single contribution Gross Net* Personal (payable net of basic rate income tax) Please note you could suffer a tax liability if contributions are funded from a tax-free cash sum received from a registered pension scheme. * The net contribution must be based on current basic rate income tax applicable to the year in which relief is being claimed. This net amount may vary in future if basic rate income tax is altered. Note: For information regarding contribution minimums and allocation, please refer to the Personal Pension/Personal Retirement Account Member s Guide. D New investment instructions for regular or single contributions Please complete this section if you: a) are paying regular contributions for the first time b) want to change the fund choice for future regular contributions and any contracting-out contributions c) are paying a single contribution. Please note: a) If you are proposing a different investment choice for both regular and single payments, please copy this page, clearly marking Regular or Single on the respective instruction, and submit with this form. b) If you do not complete this section, future contributions will continue to be invested in the funds you have previously chosen. c) If you have both regular and contracted-out contributions, we will change the fund choice for both unless you instruct us not to. If you have a Personal Pension you may select up to 99 funds. The maximum number of funds for the Personal Retirement Account is 10. A minimum of 1% can be invested in any one fund and whole numbers only. Fund manager Full Fund name Whole % Total 100% If you do not enter complete investment instructions, Old Mutual Wealth reserves the right to allocate part or all of the investment as appropriate to the OMW Deposit Fund. If you require more space for your fund choice, please use the investment instruction continuation sheet and attach it to this application. 3
E Protection benefits The following Protection benefits are available if regular contributions are being made to a Plan/Account that started before 6 April 2001: Incapacity benefit Waiver of contribution. If you wish to include incapacity benefits or waiver of contributions for the first time, or if you wish to increase these existing benefits by more than 10%, please complete and return our Protection Benefits Supplement available from your financial adviser. This will ask you to supply detailed information about your health so that we can underwrite any benefits applied for. (3) I have a Plan/Account that began before 6 April 2001 and wish to add incapacity benefit or waiver of contribution or amend my existing benefits by more than 10%. I have enclosed a completed Protection Benefits supplementary form. If you have ticked the box above and do not have life cover or wish to increase existing life cover, please go to section F. If you already have existing protection benefits in place and wish to increase them by 10% or less, please complete the section below. Incapacity benefit (Payment will be capped, please refer to your members guide.) each year Payment type Increasing Level Waiver of contribution benefit Payment type Yes Increasing No Level Life cover You may apply to increase an existing life cover by 10% or in line with the options described in your member s guide. You cannot add it or reinstate it if previously cancelled. If you already have life cover and wish to increase it by 10% or in line with the options described in your member s guide, please complete the section below. Sum assured Type of cover for sum assured (3) Guaranteed cover Bonus cover Guaranteed cover chosen benefits payable including the value of employer s contributions; Bonus cover chosen benefits payable as well as the value of employer s contributions (if any). Please note that no further underwriting will be required for these life cover increases. Any protection benefits chosen are guaranteed to remain in force for one year between Review Dates, provided that regular contributions continue at least at the level required. F Declaration You must complete this section. Any omission or misstatement of a material fact in this application form could affect the payment of benefits under the arrangements comprising the Personal Pension/Personal Retirement Account. A material fact is one which is likely to influence the assessment and acceptance of this 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. Declaration a) I declare that, to the best of my knowledge and belief, the statements made in this application and any related documents are correct and complete and that I have not concealed any material fact. b) I declare that if I am no longer eligible to tax relief on my contributions or if I am no longer a UK resident i will inform you. I will give this notice by the later of: i) 5 April in the year of assessment in which the event occurs; and ii) the date which is 30 days after the occurrence of that event. c) I agree to supply information relevant to the Personal Pension/Personal Retirement Account as shall be required by the Scheme Administrator from time to time. d) I declare that my occupation and employer (if applicable) is the same as stated in my original application unless I have informed you otherwise. e) I confirm that the specified changes should occur from the effective date I have chosen and where contributions are being collected by direct debit, the new contributions should be collected. f) I undertake to inform Old Mutual Wealth in writing of any material fact occurring before the protection benefits applied for in this application are accepted by Old Mutual Wealth. I understand that failure to do so may result in the proposed protection benefits being cancelled so that no protection benefit will be payable. g) I declare that the total contributions paid by me or on my behalf to any registered pension scheme on which I am entitled to tax relief at source do not exceed the higher of the basic amount ( 3,600), and my relevant UK earnings for that tax year. h) I consent to Old Mutual Wealth seeking medical information from any life office to which a proposal for life assurance has been made on my life and I authorise the giving of such information. I agree that a copy of this authority shall have the validity of the original. i) I declare that contributions made to the Plan have not been funded from a tax-free cash sum to the extent that neither myself nor Old Mutual Wealth will suffer a tax liability. j) I confirm that I have seen and read the privacy notice at www.oldmutualwealth.co.uk/privacy 4 continued
F Declaration Legal Guardian Declaration a) I understand the contributions paid to the contract may only be returned to the member in the form of benefits payable under the rules of the personal pension scheme. b) I declare that I am responsible for the contract until the member reaches 18. c) I declare that I will be responsible for ensuring that contribution limits in respect of the minor are not exceeded. d) I agree to advise Old Mutual Wealth of the National Insurance number of the minor when they reach age 16. This form acts as an application for tax relief at source on your contributions. It is therefore a serious offence to make a false statement. The penalties are severe and could lead to prosecution. Signature of Member (if member is 16 or over and in employment or 18 and over) Signature of Legal Guardian (if member under 16 or between 16 and 18 and not in employment) *SIGPPP01* Date D D M M Y Y Y Y PLEASE ATTACH YOUR CHEQUE FOR THE REGULAR CONTRIBUTION (IF APPLICABLE) AND/OR ANY SINGLE CONTRIBUTION. The Scheme Administrator undertakes to administer the Scheme in accordance with the Rules. A copy of this completed application form is available on request. 5
G Employer s section This section should be completed by the employer who is remitting contributions (employer and/or personal) to Old Mutual Wealth for the applicant s Personal Pension/Personal Retirement Account. Do not complete this section if the employer is remitting contributions for more than one employee. Please complete the form setting up contributions to your employees personal pensions. The applicant s Personal Pension/Personal Retirement Account is a contract between Old Mutual Wealth and the employee, although either the employer, the employee or both can contribute. All employer s contributions must be paid gross. Employee s personal contributions are based on a gross contribution which is payable net of basic rate income tax. The employer deducts these contributions from the employee s salary after tax. The net contribution will change if the basic rate of income tax changes. Please note that we require only one direct debit instruction for payment of contributions (not one for the employer and one for the employee). Employer s and personal contributions will be collected from the same bank account using this instruction. If your existing bank details have changed, or if you are making payments for the first time, please complete and return the Direct Debit mandate at the end of this form. It is imperative that the Group Co-ordinator named below advises Old Mutual Wealth within 30 days if the member wishes to amend or discontinue payments or leaves the employer s service. If you do not complete this section we are unable to monitor payments in accordance with the Pensions Act 2004 and you may be reported to The Pensions Regulator (TPR). Group Co-ordinator (person dealing with correspondence) Address Telephone number Please provide the information below: Pay day (see note 1 overleaf) D D M M Y Y Y Y Due date for regular contributions (see note 2 overleaf) Contributions due 1 9 M M Y Y Y Y Regular contribution Gross Net* Employer Employee Employer Employee Single contribution Gross * Net equivalent based on current basic rate income tax. Net* Total REGULAR contribution** Total SINGLE contribution** each month each year ** The total contribution should equal the total of any GROSS employer contribution and any NET employee contribution. For regular contributions this will be the amount of subsequent payment requests. If the amount of basic rate income tax is changed in the future we will vary the amount requested. continued 6
G Employer s section (continued) Notes 1. The pay day is the date of your payroll. 2. The due date will always be the 19th of the month following the month in which the deductions were made from payroll. Please note, this is the final due date under The Pensions Regulator (TPR) requirements. The date by which Old Mutual Wealth must receive the payment is the 1st of each month. Declaration 1. We declare that to the best of our knowledge and belief the statements made in this section and any related documents are correct and complete and that we have not concealed any material fact. 2. We agree to pay to Old Mutual Wealth all regular contributions by or for the Member other than any minimum contributions paid by the National Insurance Contributions Office (NICO). 3. We confirm that the Member s personal net contributions shall be deducted from their net pay. 4. We understand that, although we can contribute to Member s benefits, the contracts exist between the Member and Old Mutual Wealth and that, with the exception of 5., 6. and 7. below, correspondence will take place between the Member and Old Mutual Wealth direct. 5. We understand that we will be responsible for dealing and corresponding with Old Mutual Wealth regarding the payment or non-payment of contributions by or on behalf of the Member. 6. We undertake to advise Old Mutual Wealth within 30 days of the Member ceasing to be employed by us or where contributions are reduced or terminated. 7. We undertake to operate the Personal Pension/Personal Retirement Account in accordance with Old Mutual Wealth s published requirements and we agree to supply relevant information in respect of the Member which Old Mutual Wealth may require from time to time. 8. We understand that if any payment due is not received by Old Mutual Wealth within 90 days of the due date, or where Old Mutual Wealth feels that non-payment is of material significance, you may be required to advise The Pensions Regulator (TPR) and the member. 9. We understand that it is our responsibility to ensure Old Mutual Wealth is provided with relevant information to monitor payments and that should we fail to provide it we will be reported to TPR. 10. We confirm that all Members have provided consent for us to include their personal information within the Schedules to be provided to Old Mutual Wealth from time to time. 11. We understand you may make our personal information available to a third party by electronic or other means for the purpose of verifying identity in accordance with the Money Laundering Regulations. Signed for and on behalf of the Employer Name Capacity (Authorised official) Date D D M M Y Y Y Y 7
Checklist member (3) Have you completed all relevant sections and signed section F? Where applicable, have you attached a cheque for the regular contribution? Have you attached a cheque for any single contribution? If contributions are payable monthly, has the direct debit instruction been completed and signed: a) by you, if you are contributing without your employer s involvement? OR b) by your employer, if employer s contributions are being made and no existing instruction is in force? OR c) by your employer, if your employer is acting as a co-ordinator for the payment of contributions? If employer s contributions are being made, or if your employer is acting as a co-ordinator for the payment of contributions, has section G or the form setting up contributions to your employees personal pensions been completed by your employer? Have you initialled any amendments or corrections? Checklist - employer (3) Have you completed and signed section G or the form setting up contributions to your employees personal pensions? Have you completed a direct debit instruction where relevant? Have you enclosed a cheque for the total regular and/or single contributions? Have you initialled any amendments or corrections? Checklist - financial adviser (3) Have you completed and attached a Confirmation of Verification of Identity form? www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. PDF1786/218-1210/July 2018 8
Instruction to your bank OR building society to pay by Direct Debit Please complete the form and send to: Old Mutual Wealth, Old Mutual House, Portland Terrace, Southampton SO14 7AY Name and full postal address of bank/building society branch Service user number 9 1 0 1 5 9 Reference To: The Manager B Address bank/building society Instruction to your bank or building society Please pay Old Mutual Wealth Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Old Mutual Wealth and, if so, details will be passed electronically to my bank/building society. Name(s) of accountholder(s) Signature(s) Date / / / / Bank/building society account number Branch sort code - - Banks and building societies may not accept Direct Debit Instructions for some types of account. Third party payer details this is not part of the Instruction to your bank or building society Where the accountholder is not the policyholder, please provide the full name, date of birth, address and telephone number of the accountholder. The accountholders personal information may be made available to a third party by electronic or other means for the purpose of verifying identity in accordance with Money Laundering Regulations. In some circumstances the policyholder may be the only person permitted to pay premiums/contributions. Please contact Old Mutual Wealth if you have any queries with this. Full forename(s) Address Surname Date of birth - - Telephone number This Guarantee should be detached and retained by the payer. The Direct Debit Guarantee. This Guarantee is offered by all banks and building societies that accept Instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Old Mutual Wealth will notify you five working days in advance of your account being debited or as otherwise agreed. If you request Old Mutual Wealth to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by Old Mutual Wealth or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when Old Mutual Wealth asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. 9
Old Mututal Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. PDF1786/218-1210/July 2018 Old Mututal Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. PDF1786/218-1210/July 2018 Old Mututal Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years. Old Mutual Wealth Life Assurance Limited is registered in England & Wales under number 1363932. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services register number 110462. VAT number 386 1301 59. PDF1786/218-1210/July 2018 10