ADDITIONAL PREMIUM (TOP-UP) PROPOSAL FORM Please complete this form in block capitals in black ink and return it to: Hansard Europe dac. For portfolio bond additional premiums use form EO0344O. 1. PREMIUM DETAILS EOU number New policy number (if required and allocated) Full name(s) of proposer(s) Please state existing policy number Currency Request for additional premium I hereby request that an additional premium of Figures Currency Words be accepted under the provisions of Product name Frequency of premium Single Monthly Quarterly Half-yearly Yearly Payment method for additional premium Cheque Standing Order/Telegraphic Transfer - If you wish Hansard Europe dac to send the instruction to the bank, then Hansard Europe dac requires the original. Credit card - For use with regular premiums only. International Direct Debit - Please note that Hansard Europe dac must receive the original before the direct debit instruction is sent to the bank. For use with regular premiums only. UK Direct Debit - Please note that Hansard Europe dac must receive the original before the direct debit instruction is sent to the bank. For use with regular premiums only. Other Please state Term for additional premium is EITHER Please note that cash, traveller s cheques, bearer assets and banker s drafts are not acceptable forms of payment. Payment(s) must be made in favour of: Hansard Europe dac years; or maturity date to be as close to that of the original policy. If you tick the maturity box your policy will mature within same year as your base policy and within the month that the additional premium policy is issued. This does not apply to policies with no maturity date. If the premium is monthly, quarterly, half-yearly or yearly, please enclose a long term payment method. If it is more than two years since you last provided us with suitably certified evidence of identity and current proof of residence, then please provide these items with this form. Evidence of your identity should be a copy of your current Passport or National Identity Card; proof of current residence should be less than three months old. Page 1 of 6
First proposer Identification type Passport 1 National Identity Card 1 Other 1 Please state ID document number Issued by Tax identification number Second proposer Identification type Passport 1 National Identity Card 1 Other 1 Please state ID document number Issued by Tax identification number If additional life cover is required please complete an Underwriting Proposal Form (EO0044O). It is assumed that the instructions held on the existing policy also apply to this additional premium (for example beneficiaries). A new instruction for any change will be required. Please indicate the choice of unit funds required in section 2. 1 A certified copy must be supplied, see Important Note 7. 2. UNIT FUND CHOICE Unit Fund Code 2 Unit Fund Name Percentage Unit Fund Code 2 Unit Fund Name Percentage TOTAL 1 0 0 % 2 Please note that if the unit fund name and code do not agree, written clarification of your instructions will be necessary before your proposal form can be processed. 3. SOURCE OF PREMIUM PAYMENT This section must be completed by the proposer(s) and a copy of the bank transfer instruction will also be required. If the aggregate premiums (including other Hansard Europe dac policies that you hold): are equal to or exceed EUr 1,000,000 for a single premium policy, or currency equivalent; or are equal to or exceed EUr 75,000 per year for a regular premium policy, or currency equivalent; or for all policies that you hold with Hansard Europe dac are equal to or exceed EUr 1,000,000; or do not originate from an account held in the proposer s name in a Financial Action Task Force (FATF) member country you must also complete a Source of Wealth Questionnaire (EO0395O). 1. a) Please provide details and the value of all your assets and debts held: Liquid assets (deposits) Equities Real estate Other investments (specify) Debt Page 2 of 6
b) What is the value of your overall portfolio? Currency Amount c) Please provide full details and description of the source of premium to be invested for example, investments, personal income, borrowing, personal savings, pension, other. Please note additional information may be required if insufficient information is provided. d) Please provide details of your annual earned income for example, employer s name, annual gross salary 2. Where is the premium for this additional premium being sent from? a) If this is a regular premium top-up do not complete 2a but attach a long term method of payment. Please complete all the account details in full. Failure to do so will result in the Company requiring additional documentation to establish the link between you and your premium. Name of Financial Institution/Bank Financial Institution/Bank address Name of account holder(s)/policyholder(s) Account number Sort Code IBAN BIC b) If your premium is being funded by a third party 3, please provide these details Full name and address of third party (individual, corporation, insurance company) Details of the source of the premium payment of the institution or third party Name of Financial Institution/Bank/Insurance Company Financial Institution/Bank/Insurance Company address Name of account holder(s)/policyholder(s) Account number/ policy number IBAN BIC Details of the relationship between you and the third party Sort Code 3 We will require certified identification and proof of residence of the third party funding this payment. The Company reserves the right not to accept payments by third parties. Page 3 of 6
Reason for the third party making the payments/reason why you are not making the payments 3. Please provide name and contact details of the ultimate beneficial owner(s) or controller(s) if not the policyholder Important Please note that cash, traveller s cheques, bearer assets and banker s drafts are not acceptable forms of payment. 4. IMPORTANT NOTES 1. If you become resident in the republic of Ireland or the United States of America while your policy is in force this may affect the status of your policy. If you become resident in the republic of Ireland while your policy is in force, the prevailing Irish tax law will apply under Irish Tax legislation. If you become resident in the United States of America, the Company may not be able to accept the payment of any further premiums or accept any instructions to vary the unit fund choice until after you cease to be resident in the United States of America. 2. The Company will only accept a proposal introduced by an independent insurance intermediary. Your independent insurance intermediary is acting solely as your agent when advising you and submitting your proposal form to the Company. Accordingly, the Company cannot be held responsible for the advice, representations, acts or omissions, made in connection with your proposal. It is, therefore, your responsibility to make sure that the proposal form conforms with your instructions before you sign it. 3. All premiums must be made payable to Hansard Europe dac. The Company will not accept responsibility where premiums are made payable to a third party. Where a premium is made payable to a third party, that third party shall be acting solely as your agent and not as a collecting agent for the Company. 4. No liability can be accepted by the Company for any country s current or future tax or other legislation which may affect the policy including any benefit that may be payable under it. You should seek independent advice on the applicable legislation in your country of residence. 5. If you request the Company to communicate with you by email, you agree that this is entirely at your own risk and this will be taken as confirmation that you understand that email communication is not secure and may be intercepted by unauthorised third parties. In such circumstances, you will be taken as agreeing that the Company shall not be held responsible in any way should emails be intercepted by unauthorised third parties who gain access to your personal data. 6. We will use the information provided by third parties to confirm your identity and to process and record your instruction. It may also be provided to industry databases to prevent fraud and hence be shared with other insurance providers and private investigators. The Code of Practice on Data Protection for the Insurance Sector, approved by the Irish Data Protection Commissioner, contains guidelines for such use. 7. Where copies of customer identification documents are being sent to Hansard Europe dac, these documents must be certified in accordance with the Company s Prevention of Money laundering and Terrorist Financing Booklet, for Independent Insurance Intermediaries. Your independent insurance intermediary can provide you with any further information. Documents must be certified by an acceptable category of certifier as being A true copy of the original and must also be signed and dated by the certifier. The following individuals are examples of persons whom the Company accepts as acceptable certifiers: A regulated Intermediary, or an authorised employee of a regulated Intermediary, that is subject to regulation in a FATF member country; Police officer; Practising chartered & certified public accountant; Notary public/practising solicitor. Proof of residence should be in the form of a utility bill, bank statement, a current driving licence, proof of ownership or rental of residential address, a mortgage statement, tax assessment document or a letter from your employer (not more than three months old). Page 4 of 6
5. ADDITIONAL NOTES Any additional notes made below by or on behalf of the proposer MUST be countersigned by the proposer. 6. DATA PROTECTION I provide the Company the information supplied on or in conjunction with this application form in order to assess and decide upon my application for insurance (and any renewals or new insurance products) and to administer my policy (and any renewals or new insurance products). I acknowledge that the information will be held on the Company s records (both manual and electronic) and processed in accordance with the terms established in the Privacy Policy document (EO0509O). I, and any party to this application can request that any information concerning us contained in any files used by the Company and any provider of administrative services (within the restrictions of a data processing service agreement) be sent to us, deleted or rectified. The right of access, deletion and rectification can be exercised at the Company s address shown at the end of this application form and in accordance with the Privacy Policy document (EO0509O). 7. DECLARATIONS To be completed in full by each individual proposer. I HEREBY DECLARE that: 1. To the best of my knowledge and belief, the above statements are true and complete and shall form the basis of the policy applied for above. I understand that completion of this proposal form does not in itself establish a policy and that the Company has the right to refuse a proposal. 2. This proposal form conforms with my instructions before I signed it and submitted it to the Company. Any alteration made to the proposal form has been initialled by myself or by my authorised agent. If any person other than myself shall have completed any part or all of this proposal form they did so with my full authority and not on behalf of the Company, and I further declare that the completed proposal form fully conforms with my instructions. If any additional notes have been written in section 5, I have countersigned these to signify that I have read and agreed to these notes. 3. I have read and understood the Privacy Policy document (EO0509O). 4. I understand that, although most unit funds are priced daily, some unit funds are priced at weekly, monthly or quarterly intervals and that premiums due to be allocated to such unit funds will be held in a non-interest bearing account until the next unit price is declared. I have verified and understood the pricing frequency of the unit funds I have selected. 5. My independent insurance intermediary is acting solely as my agent in respect of this proposal form. Until I give the Company written notice to the contrary, my independent insurance intermediary shall continue to act in this capacity once the policy has been issued. My independent insurance intermediary is responsible for advising me on the suitability of the policy and choice of unit funds, in the context of my personal circumstances and, as such, no claim will be made by me against the Company for the advice, representations, acts, omissions or conduct of my independent insurance intermediary. 6. The Company has not provided me with any financial or other advice in respect of my policy or in respect of any of my choice of unit funds. My independent insurance intermediary is solely responsible for advising me on the suitability of the policy and the unit funds, based on my personal financial circumstances. The Company has not and does not make any warranty or representation as to the suitability of the policy for my needs. I declare that: (a) I shall be, and shall remain, solely responsible for the selection of the unit funds and that I am satisfied that such selection is appropriate for me; and (b) I am aware of and personally accept the risks and charges associated with investing in the unit fund (such as the possibility of a fund suspension or liquidation, and the application of additional penalties or market value adjustments where appropriate on the underlying assets) before deciding to invest in it; and (c) the Company has not promoted the unit funds, made any recommendation, expressed any opinion whatsoever to me in respect of the performance, risk, regulatory issues, security (including any express or implied guarantees) of the unit funds; and Page 5 of 6
(d) for the purpose of a unit fund linked to a specialist asset, my instruction to make this investment shall come with a deemed representation that I fall within the parameters set out in the particulars for that asset and I accept that the Company is under no obligation to verify this; and (e) I agree to indemnify and keep you indemnified against all claims, costs, demands, liabilities, expenses, damages or losses (including without limitation any consequential losses, loss of profit and loss of reputation, and all interest, penalties and legal and other professional costs and expenses) arising out of or in connection with my choice of unit funds. 7. I will inform the Company immediately of the details of my new address if during the life of this policy I change my residential address and/or my correspondence address. 8. I was present in when I received the advice of the independent insurance intermediary. My actual country of residence is First proposer Country Second proposer Country First proposer Second proposer (please state country) s (trustee, authorised signatory) Please print full name Position or capacity Please print full name Position or capacity Independent insurance intermediary Please print full name Hansard Europe dac Suite 201, SOBO Works, 2 Windmill Lane, Dublin 2, Republic of Ireland, D02 F206 Telephone: +353 1 211 2800 Website: hansard.com Registered Number: 219727 Registered Office: IFSC, 25/28 North Wall Quay, Dublin 1, Republic of Ireland, D01 H104 Hansard Europe dac is regulated by the Central Bank of Ireland (www.centralbank.ie) EO0036O 19/06/18 Page 6 of 6