Corporate Investment Bond Application Form from Aviva Life & Pensions UK Limited ( Aviva ) Which Investment Bond Option are you applying for? Option A Option B Option C1 Option C2 Option C3 Option D1 Option D2 Agency Number Before completing this form, please read the Investment Bond Brochure and Key Features document given to you by your Financial Broker. A. Checklist of documents to be given by you TO YOUR FINANCIAL BROKER with this completed application form. The Company Cert of Incorporation or Company print out from CRO/Vision Net/Solo Check THESE DOCUMENTS ARE REQUIRED FOR 2 DIRECTORS AND FOR ANY BENEFICIAL OWNER(S) WHO OWN OR CONTROLS 25 OR MORE OF THE SHARES OR VOTING RIGHTS OF THE COMPANY. The Directors / Beneficial Owners List of Directors and Beneficial owners on company headed paper or Company print out from CRO/Vision-Net Solo Check One copy of Photo ID for two Directors/ All Beneficial owners (one of these*) One copy of address verification per Director/Beneficial owners (one of these)* Tax Residency A current passport A current drivers licence A current national identity card. A utility bill (e-statements are acceptable) A bank statement (e-statements are acceptable) A credit card statement (e-statements are acceptable) A mobile phone bill (e-statements are acceptable) An official document from the Revenue Commissioners / Department of Social Protection A house or motor insurance certificate / document A local authority bill A court document, such as a Grant of Probate A TV licence renewal notice. A Self-Certification Declaration Form for each controlling person. Your financial broker will provide you with this form. *All Address documents must have been issued within the last 6 months. For utility bills, the supply address and billing address must be the same. B. As part of our Anti Money Laundering Obligations, we must have the following information confirmed on the application form: Where is the money being paid from (Source of Funds) Please complete your bank account details on the application form, unless it s a personal cheque in which case bank account details are not required. Where has the money come from (Source of Wealth) Please see section 5 for full details. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is authorised by the Prudential Regulation Authority in the UK and is regulated by the Central Bank of Ireland for conduct of business rules. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is also regulated in the UK: by the Prudential Regulation Authority for prudential rules and, to a limited extent, by the Financial Conduct Authority for applicable UK conduct rules. Registered Branch Office in Ireland (No 906464) at One Park Place, Hatch Street, Dublin 2. Tel (01) 898 7000 Web www.aviva.ie Registered in England (3253947) at Wellington Row, York, YO90 1WR.
Regular Saver 1. Company Company Name Please insert the details of the company that is applying for the Investment Bond. Company Address Telephone Company Email 2. Director details First Director Title Forename Surname Present Home Address Please include your email address for Aviva online access. Telephone Email Second Director Title Forename Surname Present Home Address Please include your email address for Aviva online access. The minimum contribution for Investment Bond are: 2 Telephone Email 3. Investment Details I/We wish to invest in the Investment Bond as follows: Amount to be invested e (this amount is inclusive of government levy) WARNING: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance Intermediary. 4. Fund Choice Please complete details of your fund choice and the proportion of each fund you d like to invest. Please note, we can only accept whole percentage numbers. Fund Choice Percentage 100 If you wish to invest in one of our AIMS Funds, please specify if you wish to invest in the AIMS Target Income Fund (Ireland) or the AIMS Target Return Fund (Ireland). Option A: 10,000 ( 25,000 if regular withdrawal facility is required) Option B: 25,000 Option C: 50,000 Option D: 20,000 ( 25,000 if regular withdrawal facility is required) You can chose to invest in any of the fund options listed in our fund guide, Your Investment Options. There is a minimum investment of 10 per fund. Please see our Fund Guide, Your Investment Options for full details on all of our funds, and speak to your Financial Broker. When your fund choice includes the Aviva Investors Multi- Strategy (AIMS) Target Income Fund (Ireland), your policy will be closed to transactions across all funds on certain days around the date the income is declared by us (please see the Supplementary Conditions for exceptions). These policy closed days are there to facilitate fairness in the administration of the monthly income. You can find out when the policy closed days are from us or from your financial broker.
5. Anti-Money Laundering Requirements As part of our Anti-Money Laundering requirements, we are obliged to obtain certain documents and information listed below. (i) Identification of the Company Cert of incorporation or Company printout from CRO / Vision-Net / Solo Check (ii) List of Directors and any Beneficial Owners (ii) Identification of two Directors and all Beneficial Owners Photo ID and address verification attached for 1st Director 2nd Director Beneficial Owner(s) (iv) Source of Wealth Please advise the origin of the funds being invested Company earnings Sale of investment Regular savings Regular Saver Photo ID must be current and address verification must have been issued in the last 6 months. Please see the checklist at the start of this application for examples of documentation accepted. Photo ID and address verification is required for 2 directors and all beneficial owners. A Beneficial Owner is someone who owns or controls 25 or more of the shares or voting rights of the company. Reinvestment Aviva policy Other corporate investment (All reinvestments must be an investment held by the company named in Section 1) Other (Please specify) Aviva reinvestment policy number (if relevant) (v) Source of Funds Please advise the method of payment of the funds being invested. Cheque from applicant company s bank account Electronic funds transfer (EFT) Bank draft Please provide details of the bank account from which the funds for the policy were paid unless method of payment is a company cheque from the applicant company bank account Company/Policyholder Account Name Account number IBAN If you wish to transfer funds to us via EFT, our bank details are: IBAN - IE16ULSB98501050090653 BIC - ULSBIE2D Please quote your application number or full name. Bank identifier code BIC Your IBAN and BIC are shown on your bank statement. 6. Tax Residency We re obliged to obtain the tax residency status of all controlling persons of the Company named in section 1. You must complete the separate Self-Certification Declaration Form for Entities for each controlling person your financial broker will give you this form for completion. Please ensure that the signature of the controlling person is included in Q5 of the form, with additional forms completed for each controlling person if necessary. Self-Certification Declaration Form for each controlling person attached This mandatory section, and the Self-Certification Form, to be completed by the policyholders in compliance with the Foreign Account Tax Compliance Act (FATCA) and Automatic Exchange of Information (AEOI). For further information on FATCA or AEOI, please refer to the Irish Revenue website at http://www.revenue.ie/ en/business/aeoi/index.html 3
Regular Saver 7. Company Tax Declaration Please supply your Company Name and Tax Number in the fields below. Tax will be levied at the individual rate if this declaration is not completed. Company Name Company Tax Reference Number I declare that the Company Tax Reference number is correct and that the policyholder is a Company eligible to be treated for Corporate Exit Tax. Signature of Authorised Signatory 1 Please complete this section to confirm that the company is eligible to pay Exit Tax at the corporate rate If you choose Option A, D1 or D2 and wish to use the regular withdrawal facility, the initial single contribution invested must be at least 25,000. Signature of Authorised Signatory 2 Date / / For and behalf of (company name) Income payments must be lodged to your Irish company bank account. We cannot make income payments by cheque. 8. Regular withdrawal facility You can take regular withdrawals from your investment, subject to the Aviva minimum and maximum limits as set out in section 5.2 of your Policy Conditions, or if your fund choice includes the AIMS Target Income Fund (Ireland) section 2.2 of your Supplementary Conditions. A copy of these conditions is available on request from us or your financial broker. Within these limits you can choose to take regular withdrawals as a monetary amount, as a percentage of the investment accumulated value, or where your fund choice includes the AIMS Target Income Fund (Ireland), the value of the additional units added to reflect the monthly income declared by the fund. Please advise amount or of investment. Please see margin for details of minimum/maximum amounts Amount of regular withdrawal of current investment value* Or monetary amount* e Or AIMS Target Income Fund (Ireland) monthly income only* *Gross of exit tax Frequency of withdrawal (tick as required) Monthly Quarterly Half Yearly Yearly When your fund choice includes the AIMS Target Income Fund (Ireland): any regular withdrawal will be monthly only. You cannot take quarterly, half yearly or yearly regular withdrawals supplementary conditions will apply. First payment due* / / Name of Bank Address of Bank Account Name Account number IBAN If you elect to take a regular withdrawal from the AIMS Target Income Fund (Ireland) as the monthly income paid by the fund only, the minimum regular withdrawal is the fund income cancellation amount (value of the units added to reflect the fund s monthly income). Regular withdrawals will be subject to the following minimum and maximum amounts: If you wish to take a regular withdrawal as a monetary amount, then the minimum regular withdrawal is 2 of your original contribution per year and the maximum is 7.5. If you wish to take regular withdrawals as a percentage of your Investment Bond s value, then the minimum regular withdrawal is 2 of the value of your Investment Bond per year, and the maximum is 7.5. Exceptions to these minimum and maximum limits apply where your fund choice includes the AIMS Target Income Fund (Ireland). You can find more details on this exceptions in the Supplementary Conditions and the Aviva Investors Multi- Strategy (AIMS) Target Income Fund (Ireland) Key Features for Investment Bond customers. Bank identifier code BIC *Note: Income payment coincides with start date of the bond and is paid on that date each month (with exceptions for policy closed days, weekends, bank holidays and other exceptional circumstances), quarter etc. Please allow up to 7 days for monies to reach Bank/Building Society Accounts. 4
9. Declarations and Mandate Declaration of Intermediary I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the applicant(s) has been provided with the information specified in Schedule 1 to those Regulations and that I have advised the applicant(s) as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction and of possible financial loss as a result of such replacement. I also declare that, in accordance with the legal and statutory requirements on money laundering and terrorist financing, in certifying identification documentation, I, or a person authorised by me, have met with the individual on a face to face basis, have seen the original documents and can confirm that the photograph bears a true likeness to the individual. I understand that Aviva will be relying on this declaration. Signed Date / / Regular Saver Please note carefully This is a legal document and forms part of the basis of the contract. All sections must be fully completed and any alterations initialled by the signatory/signatories. Failure to provide true and complete information shall render the contract void. A copy of the completed application form is available on written request, and a copy of the policy conditions is available on request. Name of insurer or Financial Broker Authorised Signatory Mandate Date / / Company Name We request and authorise Aviva to accept written instructions, including but not limited to those set out below, from one or more of the authorised individuals. Surrender Part surrender Fund switch Amend the signatory list Change of agency Changes to the policy which Aviva requires written instruction Authorised signatory list Name Signature If there are more than 10 authorised signatories, please include a separate mandate on company headed paper, signed and dated by two directors. If this list changes, you need to let us know. 5
Regular Saver Declaration of Company 1. The Company consents to Aviva, verbally or otherwise, seeking and receiving additional information from it and from the Life/Lives Insured or the Company s agents that isn t provided on the application or where further information is required in order to process the application and such information will be deemed to be incorporated into this application. 2. The Company declares that the information in this application for this Investment Bond policy is true and complete. 3. The Company agrees that without further communication to me/us Aviva may, if they accept this application for this Investment Bond policy, issue a policy comprising policy conditions on Aviva s standard terms for policies of this type (a copy of which has been made available to the Company) and a policy schedule as regards the particulars of the policy such as single contribution amount, fund choices and charges. 4. The Company agrees that the policy conditions and policy schedule together with the information in this application for this Investment Bond policy will form the contract between Aviva and the Company. 5. The Company agrees and understand that if any contribution is tendered, no binding contract is created until Aviva Life & Pensions UK Limited has issued the policy. 6. The Company confirms that it is resident for tax purposes in the Republic of Ireland and is not resident in the US. The Company undertakes to inform Aviva of any change in its country of residence during the life of the policy. 7. The Company agrees and understands that Aviva s processes may involve electronic means including, but not limited to, data entered online, the capturing of signatures on an electronic device, the use of electronic signature or the use of a signature-free process; Aviva s processes may also (even where commenced on-line) involve manual processes and/ or require wet ink signing of documents at certain points. 8. The Company confirms that it has received in writing the information specified in the above intermediary declaration. 9. The Company understands and agrees to the Data Protection Use of Information Notice in section 10. 10. I/We the persons authorised to sign this on behalf of the Company understand and agree to the Data Protection Use of Information Notice in section 10. Signature of Authorised Signatory Date Signature of Authorised Signatory / / / / Declaration of Life/Lives Insured 1. I/We declare that the information given to Aviva in section 2 and section 6 in the application for this Investment Bond policy is true and complete. 2. I/We understand and agree to the Data Protection Use of Information Notice in section 11. Signature of First Director Life Insured Date Signature of Second Director Life Insured / / / / 10. Data Protection - Use of Information Notice The information you provide about yourself and about third parties will be held by Aviva Life & Pensions UK Limited (the data controller) and may be used, stored and processed by Aviva Group companies (together, we, us or our ), our commercial partners, authorised agents/service providers and/or successors, on computer systems and/or in paper files for the following purposes: (a) to provide and administer financial services/products requested by you; (b) to comply with applicable legal or regulatory obligations; and (c) for other legitimate business interests of Aviva Life & Pensions UK Limited, including marketing that you have permitted and protection against non-disclosure of material facts and fraud. In connection with these purposes, information may be shared, both inside and outside the European Economic Area, with our other insurance and financial services companies including those within the Aviva Group and third parties such as reinsurance companies, medical practitioners, Insurance Ireland, trustees/administrators and sponsoring employers of pension plans, other insurance and financial services companies, our service providers such as those to whom we outsource certain business operations, professional advisers, private investigators who may be instructed to investigate a claim, reputable external agencies and as required by law. 6
To assist in preventing, detecting and/or protecting our customers and ourselves from theft and fraud, we may also use your information to make searches of our records. If you give us false information or fail to disclose information and we suspect fraud, we will record this. In the event of your application not proceeding or your policy ceasing, information provided in connection with such may be retained for as long as is permitted by law and may be shared as outlined above where applicable. Where sensitive personal data, for example data relating to your physical or mental health, are provided by you or on your behalf, access to and disclosure of this information will be restricted to that necessary for the purposes set out above, in particular for administering contracts of insurance/products requested by you (including underwriting, processing, claims handling, reinsurance, protection against non-disclosure and fraud prevention). You may request, in writing, a copy of your information held by us. Please write to The Data Protection Officer, at our branch, Aviva Life & Pensions Ireland, One Park Place, Hatch Street, Dublin 2, together with payment of the applicable fee (currently 6.35). You may be asked to prove your identity before your request is met. If you believe there may be inaccuracies identified in the information held about you, then you can contact The Data Protection Officer to have such corrected, to block certain uses or object to the processing of your personal data. You confirm, by signing the declaration in section 9, that you have fully explained to each person whose information has been provided to us by you in connection with this policy, the purposes and use for which that information has been provided and how the information may be used, in the same detail as set out in this form and that each person has explicitly consented to such. For customers with a tax status outside the Republic of Ireland, we may share information with the Irish Revenue Commissioners in order to comply with the Foreign Account Tax Compliance Act (FATCA) and Automatic Exchange of Information (AEOI). The Irish Government has and will be entering into a number of inter-governmental agreements to share tax information, where applicable, with the tax authorities in other territories. The requirement to collect information about each customer s tax residence is part of ROI legislation and as a financial services company we are legally obliged to collect it. We are asking for your tax residency and tax identification numbers (where applicable) and will record this on our records. We may report the relevant information listed below to Revenue and they may transfer that information to the government of that territory in accordance with the relevant agreement. - Name, address, jurisdiction of tax residence, Tax Identification Number (TIN) and date of birth. - Policy number and that the policy is held with Aviva. - The value of the policy at the end of the year or at the date it was closed - The gross amount of interest, dividends, proceeds from sale or redemption or other amounts paid or credited to the controlling person or policy during the year. In accordance with those agreements, Irish Government will also begin to receive information from Governments of other territories about non-roi accounts held by ROI tax residents. Marketing We would like to use your details to provide you with information about other financial or insurance products, services and special offers either from us or other Aviva Group companies, or products, services and special offers which any member of the Aviva Group may arrange with a third party. Your details may also be used for this purpose (for up to 12 months) after your policy has ceased. Your details may be used for this purpose if the policy does not proceed, for up to 12 months after the date of the quotation. Please tick here if you do not wish to receive such information from us. Your choice will not affect any of the services we provide to you, now or in the future. By submitting this application or if you have any other communication with Aviva Life & Pensions UK Limited through or in relation to its products and services, you acknowledge the foregoing and consent to the processing of the personal data as indicated above. In particular you acknowledge and explicitly consent to the arrangements in relation to sensitive personal data as indicated.
11. For Financial Adviser use only Please ensure all relevant questions are answered before submitting the application form. 1. Name Present Address Financial Adviser No. Name of Salesperson Salesperson Reg. No. (LARC) Commission Basis Special Instructions For office use only Consultant Branch Date / / Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is authorised by the Prudential Regulation Authority in the UK and is regulated by the Central Bank of Ireland for conduct of business rules. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is also regulated in the UK: by the Prudential Regulation Authority for prudential rules and, to a limited extent, by the Financial Conduct Authority for applicable UK conduct rules. Registered Branch Office in Ireland (No 906464) at One Park Place, Hatch Street, Dublin 2. Tel (01) 898 7000 Web www.aviva.ie Registered in England (3253947) at Wellington Row, York, YO90 1WR. 1.405.06.16