Financial adviser stamp APPLYING TO TRANSFER-IN OR CONTRACT-OUT UNDER YOUR PERSONAL PENSION Financial adviser agency number Please enter your business postcode Are you enclosing a cheque with this application? *PPPPEN01* Please use BLOCK CAPITALS only and blue or black ink. Please complete all relevant sections. If any are incomplete, we will write to you for the missing information which will delay your application. All references to Old Mutual Wealth in this application mean Old Mutual Wealth Life Assurance Limited. You should seek the advice of your financial adviser or other suitable professional before completing this form. This must be completed by your financial adviser. For new applications please confirm if you have given advice to the client in relation to this product. Please confirm that you have the FCA advising on pension transfers and pension opt-outs permission. GENERAL DETAILS This form enables you to set up a new single price personal pension plan or top up an existing plan in respect of transfer payments in respect of uncrystallised funds contracting-out of the State Second Pension (S2P). Are you already a member of the Old Mutual Heritage Personal Pension Scheme? (3) If, please enter your Plan number Do you wish to add these payments to your existing Plan? If, we will set up a new plan, for which we will need the Key Features reference. Are you submitting any other pension application form at the same time as this one? (eg a regular contribution pension) If, please provide details. IMPORTANT: KEY FEATURES REFERENCE To make sure we set up your plan correctly, please enter the reference number as shown at the foot of each page of your Key Features Illustration. If you do not, you will delay us being able to process your application. Key Features reference Dated (dd/mm/yyyy) 2 0 The reference number will be used to determine the contract you have applied for. 1 of 15
A PERSONAL DETAILS OF THE APPLICANT AND ELIGIBILITY Please complete Parts 1 and 2 if you are: n 16 or over and in employment, or n 18 or over Parts 1, 2 and 3 must be completed by your legal guardian if you are: n under 16 or, n between 16 and 18 and not in employment Part 1 Applicant s/minor s details Title (3) Mr Mrs Miss Other Full forename(s) Surname Permanent residential address (Please note that c/o addresses are not acceptable.) Postcode Date of birth (dd/mm/yyyy) Sex (3) Male Female Spouse s/civil partner s* date of birth (if applicable) Marital status (3) Single Married Widowed Divorced Separated Civil partnership* National Insurance number (if over 16) Selected Pension Age (Any birthday between 55 and 75. Other ages may be permitted in some circumstances; please speak to your financial adviser for further information. * as defined by the Civil Partnership Act 2004. Part 2 Applicant s/minor s status (3) If you have two or more sources of earnings please complete all relevant boxes below and indicate which is your main source of earnings. n Employed Where the main source of income derives from employment or the holding of an office, and is taxed as employment income. n Pensioner Where the main source of income derives from pensions and is taxed as pension income. n Self-employed Where the main source of income derives from the profits or gains arising or accruing from any trade, profession or vocation carried on by you, and is taxed accordingly. n Child under 16 n Caring for one or more children aged under 16 n Caring for a person aged 16 or over n Full-time education n Unemployed n Other (please specify) continued 2 of 15
A PERSONAL DETAILS OF THE APPLICANT AND ELIGIBILITY (continued) Part 3 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.) Postcode B CONTRACTING-OUT OF THE STATE SECOND PENSION EMPLOYEES ONLY You must be aged 16 or over to contract-out of the State Second Pension (S2P) and either paying regular and/or single contributions or have an existing Old Mutual Wealth pension arrangement. Do you wish to use your Personal Pension to contract-out of S2P? (3) If, go to section D. If, please complete this section. Please complete Joint tice form CA1542 in the enclosed supplement. Please insert the year from which you wish to contract-out. 6 April 2 0 Have you already contracted-out of S2P through another personal pension scheme? If, you must first cancel that election using HM Revenue & Customs form CA1543 in the supplement. C INVESTMENT INSTRUCTIONS Please enter your fund choice overleaf by completing this section. This instruction will apply to all payments included in this application. 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 wish to select a different fund choice for each transfer payment or payment type, please tick here and provide details on a separate sheet clearly setting out your instructions. (3) Depending on how involved you want to be in the investment selection process and your attitude to risk, we have a fund choice to suit you. We do not provide advice on the selection of funds. Your financial adviser will be able to help you choose the funds most suitable for you. You can choose from our Self Select range of individual funds and fund managers, or our MultiManager fund range, which uses the expertise of Old Mutual Wealth Investment Management to blend the skills of selected fund managers within different sectors. 3 of 15
C INVESTMENT INSTRUCTIONS (continued) You can have a minimum of 1% in any fund (whole percentages only) and up to 99 funds in total. Your fund choice must total 100%. Fund manager Full fund name Whole % If you require more space for your fund choice, please use the investment instruction continuation sheet and attach to this application. Old Mutual Wealth offer a Phased Investment and Portfolio Rebalancing Service. Full details of these are available in the Phased Fund Choice leaflet or from your financial adviser. You can use this application to select a 12-month Portfolio Rebalancing Service by completing the section below. If you do so, this will override any Portfolio Rebalancing currently in place where this is a top-up to an existing plan, and all existing funds in your plan will be rebalanced in line with the Investment Instructions detailed above. If you require an individually tailored Portfolio Rebalancing Service or Phased Investment you must complete a separate Phased Fund Choice Instruction and submit it with this application. Portfolio Rebalancing I wish to bring my entire plan, including any existing holding, back in line with my investment choice shown above, every 12 months. (3) The date of the first rebalance is to be (dd/mm/yyyy) 2 0 D COMBINED PENSION FORECAST This section applies if the Applicant is over age 16, has a National Insurance number and is not drawing state pension benefits. Do you wish to receive an annual pension forecast, referred to as a combined pension forecast, which includes information about your State Pension? (3) Please note: If you answer, the combined pension forecast will be included in the annual disclosure statement sent to you within one year of the acceptance of this application. If you answer, and are a member of any other Old Mutual Wealth pension plan, you will receive only one combined pension forecast. It will be included with the annual disclosure statement of your most recent plan. If you answer, you will not receive a combined pension forecast for this application or any other plans you hold with Old Mutual Wealth. If you fail to complete this question we will assume you wish to receive a combined pension forecast. 4 of 15
E BENEFITS PAYABLE ON DEATH You must complete this section if you are applying for a new Personal Pension or you are topping up an existing plan and wish to change your nomination. If you die before drawing pension benefits, the value of the fund may provide benefits in line with regulations. The beneficiaries will be determined at the discretion of Old Mutual Wealth Life Assurance Limited (the Scheme Administrator) in respect of any non-protected Rights funds. It is essential that the Scheme Administrator has guidance about your wishes. Please nominate beneficiaries under Option 1. If your Plan includes Protected Rights and you are married or in a civil partnership* at the time of your death, any remaining Protected Rights funds must be used to provide income for your spouse or civil partner*. You can suggest beneficiaries under Option 2 who will apply if you are single at the time of death. If you do not make a nomination and are single at the time of death, any remaining Protected Rights funds must be paid to your estate. * as defined by the Civil Partnership Act 2004. Option 1 Discretionary lump sum benefit This applies to non-protected Rights only. Please nominate beneficiaries to receive a lump sum payable at the discretion of Old Mutual Wealth Life Assurance Limited (the Scheme Administrator), and enter details in the box for Option 1. If you wish to suggest more than one person, please enter the proportion payable to each. I understand that the Scheme Administrator has absolute discretion, but in the event of my early death I should like the Scheme Administrator to consider payment of any lump sum death benefit permitted by the Rules to: Beneficiary under Option 1 Name Address % 100% Option 2 Lump sum benefit This applies to Protected Rights only. Please enter the details of your nominated beneficiaries in the box for Option 2 below. Your nomination will apply to Protected Rights where relevant. If you wish to suggest more than one person, please enter the proportion payable to each. Beneficiary under Option 2 Name Address % 100% 5 of 15
F TRANSFERRING SCHEME DETAILS Please provide details in the table below of the pension plans you wish to transfer from other providers. If you have more than four transfers please use a photocopy of this page and attach to this application. The Personal Pension is held under the Old Mutual Heritage Personal Pension Scheme which is an appropriate scheme (reference number A7001031L) registered under the Finance Act 2004. Please note: a) Old Mutual Wealth will accept transfers from UK registered pension schemes. The specific agreement of Old Mutual Wealth is required before we can accept transfer payments from an overseas source. b) Where any benefit under the transferring scheme/contract is in payment, please complete an application form for the Old Mutual Wealth Personal Pension Income Plan. c) Minimum standalone transfer payment 5,000; minimum additional transfer payment 500. Please complete this table in relation to the plan you wish to include. 1 Transfer number 2 1. Amount of transfer payment a. Does this represent the full value of the plan you wish to transfer? If, we will request the amount above. 2. Transferring scheme provider 3. Plan number 4. Is the transfer from an occupational pension scheme? If, your financial adviser must complete the question on the front page of the application. 5. Has any benefit under the transferring scheme or arrangement come into payment? 6. Does the transfer payment include any amount representing Protected Rights? a. If, please enter the amount of Protected Rights. 7. Is this transfer part of a block transfer? a. If, and the original transfer is from an occupational pension scheme set up before 6 April 2006, do you have protection in respect of a tax-free cash sum? i) If, please advise the protected amount as at 5 April 2006. b. If, and the transfer is from an occupational pension scheme with a normal retirement age under 55 on 5 April 2006 as confirmed by the scheme rules on 10 December 2003, please advise your early pension age. c. If, and the transfer is from a personal pension or retirement annuity contract set up before 6 April 2006 with a pension age under 50, please advise your early pension age. d. Please advise the value of any pre 6 April 2006 rights as at 5 April 2006. Before we can accept the transfer payment, the Transferring Scheme Administrator will be required to complete a separate Transferring Scheme declaration form. continued 6 of 15
F TRANSFERRING SCHEME DETAILS (continued) Please complete this table in relation to the plan you wish to include. 3 Transfer number 4 1. Amount of transfer payment a. Does this represent the full value of the plan you wish to transfer? If, we will request the amount above. 2. Transferring scheme provider 3. Plan number 4. Is the transfer from an occupational pension scheme? If, your financial adviser must complete the question on the front page of the application. 5. Has any benefit under the transferring scheme or arrangement come into payment? 6. Does the transfer payment include any amount representing Protected Rights? a. If, please enter the amount of Protected Rights. 7. Is this transfer part of a block transfer? a. If, and the original transfer is from an occupational pension scheme set up before 6 April 2006, do you have protection in respect of a tax-free cash sum? i) If, please advise the protected amount as at 5 April 2006. b. If, and the transfer is from an occupational pension scheme with a normal retirement age under 55 on 5 April 2006 as confirmed by the scheme rules on 10 December 2003, please advise your early pension age. c. If, and the transfer is from a personal pension or retirement annuity contract set up before 6 April 2006 with a pension age under 50, please advise your early pension age. d. Please advise the value of any pre 6 April 2006 rights as at 5 April 2006. Before we can accept the transfer payment, the Transferring Scheme Administrator will be required to complete a separate Transferring Scheme declaration form. 7 of 15
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G TRANSFER OF PENSION BENEFITS TO OLD MUTUAL WEALTH If your application includes more than four transfers, please use a photocopy of this page. Dear Sir or Madam Name of Transferring Scheme Transferring Scheme address Policy number (if applicable) Postcode Please accept this letter as my authority to pay the transfer value to Old Mutual Wealth. This is to provide me with added benefits in the receiving scheme instead of under your scheme. I authorise you to provide Old Mutual Wealth with all the information they need to accept the transfer value. I discharge you from providing benefits for me under the above-named scheme after payment of the transfer value. You have confirmed to me that you have calculated the transfer value based on equal benefits for men and women since 17 May 1990. This is in line with the European Court of Justice s rulings on equal treatment. I understand that I have no further claim against the trustees, administrators or managers of the transferring scheme. Yours faithfully Signature Date (dd/mm/yyyy) 2 0 Full name Dear Sir or Madam Name of Transferring Scheme Transferring Scheme address Postcode Policy number (if applicable) Please accept this letter as my authority to pay the transfer value to Old Mutual Wealth. This is to provide me with added benefits in the receiving scheme instead of under your scheme. I authorise you to provide Old Mutual Wealth with all the information they need to accept the transfer value. I discharge you from providing benefits for me under the above-named scheme after payment of the transfer value. You have confirmed to me that you have calculated the transfer value based on equal benefits for men and women since 17 May 1990. This is in line with the European Court of Justice s rulings on equal treatment. I understand that I have no further claim against the trustees, administrators or managers of the transferring scheme. Yours faithfully Signature Full name Date (dd/mm/yyyy) 2 0 9 of 15
Old Mutual Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Calls may be monitored and recorded for training purposes and to avoid misunderstandings. 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. When printed by Old Mutual Wealth this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF4328/210-2143R/December 2010 Old Mutual Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Calls may be monitored and recorded for training purposes and to avoid misunderstandings. 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. When printed by Old Mutual Wealth this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF4328/210-2143R/December 2010 10 of 15
G TRANSFER OF PENSION BENEFITS TO OLD MUTUAL WEALTH (continued) Dear Sir or Madam Name of Transferring Scheme Transferring Scheme address Policy number (if applicable) Postcode Please accept this letter as my authority to pay the transfer value to Old Mutual Wealth. This is to provide me with added benefits in the receiving scheme instead of under your scheme. I authorise you to provide Old Mutual Wealth with all the information they need to accept the transfer value. I discharge you from providing benefits for me under the above-named scheme after payment of the transfer value. You have confirmed to me that you have calculated the transfer value based on equal benefits for men and women since 17 May 1990. This is in line with the European Court of Justice s rulings on equal treatment. I understand that I have no further claim against the trustees, administrators or managers of the transferring scheme. Yours faithfully Signature Full name Date (dd/mm/yyyy) 2 0 Dear Sir or Madam Name of Transferring Scheme Transferring Scheme address Policy number (if applicable) Postcode Please accept this letter as my authority to pay the transfer value to Old Mutual Wealth. This is to provide me with added benefits in the receiving scheme instead of under your scheme. I authorise you to provide Old Mutual Wealth with all the information they need to accept the transfer value. I discharge you from providing benefits for me under the above-named scheme after payment of the transfer value. You have confirmed to me that you have calculated the transfer value based on equal benefits for men and women since 17 May 1990. This is in line with the European Court of Justice s rulings on equal treatment. I understand that I have no further claim against the trustees, administrators or managers of the transferring scheme. Yours faithfully Signature Full name Date (dd/mm/yyyy) 2 0 11 of 15
Old Mutual Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Calls may be monitored and recorded for training purposes and to avoid misunderstandings. 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. When printed by Old Mutual Wealth this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF4328/210-2143R/December 2010 Old Mutual Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Calls may be monitored and recorded for training purposes and to avoid misunderstandings. 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. When printed by Old Mutual Wealth this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF4328/210-2143R/December 2010 12 of 15
H DECLARATION, APPLICATION, COMBINED PENSION FORECAST AND PERSONAL DATA STATEMENT 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. 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 agree to supply information relevant to the Personal Pension as shall be required by Old Mutual Wealth from time to time. c) Where Portfolio Rebalancing has been selected as part of this application, I understand that: i) Portfolio Rebalancing will take place every 12 months from the date specified in section D. If a relevant date falls on an Old Mutual Wealth non-working day, my instructions will be carried out on the next Old Mutual Wealth working day. ii) If I am making regular contributions to my Policy, and have chosen to allocate them to funds other than those in my target selection, any units in those funds will be switched out and included in the overall rebalancing adjustments. iii) I can cancel or change my Portfolio Rebalancing instructions at any time by contacting Old Mutual Wealth in writing at their Head Office address. If I wish to change my instructions, a new set of instructions should be completed and sent to Old Mutual Wealth. These new instructions will cancel any remaining transactions from the original instructions. Instructions to cancel or change must be received at their Head Office address before 10am on the date the next switch is due to take place. iv) My instructions will automatically be cancelled in the event of any of the following: death claim transfer out or retirement claim receipt of a top-up lump sum commencement (or recommencement) of regular contributions an ad hoc switch request closure of one or more of the funds affected by my instructions merger affecting fund(s) in my instructions suspension of fund(s) in my instructions conversion of fund(s) in my instructions. v) A new set of Portfolio Rebalancing instructions will be required should I wish to reinstate the instructions. 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 (after age 55 except in the case of earlier incapacity). b) I declare that I am responsible for the contract until the member reaches 18. c) I agree to advise Old Mutual Wealth of the National Insurance number of the minor when they reach age 16. For new applications only a) I apply to become a Member of the Old Mutual Heritage Personal Pension Scheme ( the Scheme ) in accordance with this application and agree to be bound by the Rules of the Scheme ( the Rules ). b) Where an application is being made in respect of a transfer payment(s), I understand that the Personal Pension will comprise one arrangement for Protected Rights and a further arrangement of non-protected Rights included in the transfer payment(s). c) Where an application is being made to only contract-out of S2P, I understand that the Personal Pension will comprise one separate arrangement in respect of any contributions paid by the National Insurance Contributions Office (NICO). For top-up applications only I request that the changes detailed in this application are made to my existing plan. Applications for transfer payments a) I authorise and instruct the current provider to transfer funds from the plan(s) listed in this application directly to Old Mutual Wealth. Where the current provider has asked me to give them any original policy document(s) in return for the transfer of these funds and I am unable to do so, I promise to accept responsibility for any claims, losses and expenses of any nature which they may incur as a result of having made the transfer(s) listed in this application form. b) I authorise the current provider to release all necessary information to Old Mutual Wealth. to enable the transfer of funds to Old Mutual Wealth. c) I authorise the current provider to obtain from and release to the financial adviser named in this application any additional information that may be required to enable the transfer of funds. d) If an employer is paying contributions to any of the plans listed in this application, I authorise the current provider to release to that employer any relevant information in connection with the transfer of funds from the relevant plan(s). e) Until this application is accepted and complete Old Mutual Wealth s responsibility is limited to the return of the total payment(s) to the current provider(s). f) Where the payment(s) made to Old Mutual Wealth represent(s) all of the funds under the plan(s) listed in this application, then payment made as requested will discharge the current provider(s) of all claims and responsibilities in respect of the plan(s) listed. g) Where the payment(s) made to Old Mutual Wealth represent(s) part of the funds under the plan(s) listed in this application, then the current provider(s) will be discharged of all claims and responsibilities only in respect of the part of the plan(s) represented by the payment(s). h) I promise to accept responsibility in respect of any claims, losses and expenses that Old Mutual Wealth and the current provider(s) may incur as a result of any incorrect information provided by me in this application or of any failure on my part to comply with any aspect of this application. i) I confirm that, where I am transferring Protected Rights, I wish to transfer these from the current provider(s) to Old Mutual Wealth. continued 13 of 15
H DECLARATION, APPLICATION, COMBINED PENSION FORECAST AND PERSONAL DATA STATEMENT (continued) Combined pension forecast I understand that where I have chosen to receive a combined pension forecast Old Mutual Wealth will send my personal data to the Department for Work and Pensions and that personal data for this purpose means name, sex, date of birth and National Insurance number. In return Old Mutual Wealth will receive details of my state pension entitlement. All information released to and received from the Department for Work and Pensions will only be used by both parties for the purposes of providing me with a combined pension forecast. I understand that I will continue to receive a combined pension forecast from Old Mutual Wealth until I advise you in writing that I no longer wish to receive one. PERSONAL DATA STATEMENT: Consent of Applicant To: OLD MUTUAL WEALTH LIFE ASSURANCE LIMITED I agree that you may use my personal data including any sensitive personal data ( my data ) to process my application and to service my plan. I confirm that the beneficiary/each beneficiary and/or my spouse, civil partner or dependant referred to in this application (or parent where parental consent is required if a beneficiary/each beneficiary is a dependant) consents and agrees to my acting as their agent for the purposes of their personal data provided within the application being returned to you for administration of my plan. As part of this process you may provide my data, by electronic or other means, to: other companies within the Old Mutual Wealth and Old Mutual groups of companies if you regard this as necessary to service my plan my financial adviser a third party to verify my identity in line with money laundering or other requirements which may involve carrying out checks with credit reference databases third parties who perform tasks for you to help you service my plan. These third parties may be based in countries outside the EEA. These countries may not have laws to protect my data equivalent to those of the UK. However, you will ensure that any such third parties agree to treat my data with the same level of protection as if you were dealing with it. To prevent and detect fraud you may: share my data with other organisations, including the police check and/or file my data with fraud prevention agencies and databases, and if you are given false or inaccurate information and you suspect fraud, you will record this. You and other companies within the Old Mutual Wealth and Old Mutual groups of companies may use my data for assessment and statistical analysis purposes. In order to improve your system you may use my data for the purposes of system testing. You will ensure that any testing is controlled and carried out securely. My data may be made available to third parties where required by law, court order or regulation. *SIGPPP01* On payment of a small fee, I am entitled to receive a copy of my data which is subject to the Data Protection Act 1998. I also have the right to require you to correct any inaccuracies in my data. In such circumstances I can contact you at Old Mutual Wealth Life Assurance Limited, PO Box 37, Southampton, SO14 7AY. Signature of Applicant (if 16 or over) Signature of Legal Guardian (if Applicant under 18. This will be in addition to the Applicant s signature where the Applicant is 16 or over, but under 18) Date (dd/mm/yyyy) 2 0 The Scheme Administrator undertakes on behalf of Old Mutual Wealth Life Assurance Limited to administer the Scheme in accordance with the Rules. A copy of this completed application form and the Member s Guide are available on request. 14 of 15
CHECKLIST ALL APPLICANTS (3) Have you completed all relevant sections and signed section H? If you are using the Personal Pension to contract-out of S2P, have you completed the Joint tice form CA1542? If any fees are payable, have you signed the Client Fee Instruction? Have you initialled any amendments or corrections? CHECKLIST FINANCIAL ADVISER (3) Please ensure if any fees are payable a completed Client Fee Instruction is attached. Have you answered the question regarding advice at the start of this form? FOR OFFICE USE ONLY Basis Signed Old Mutual Wealth Head Office Old Mutual House Portland Terrace Southampton SO14 7AY T: 023 8033 4411 F: 023 8022 0464 www.oldmutualwealth.co.uk Calls may be monitored and recorded for training purposes and to avoid misunderstandings. 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. When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests. PDF4328/210-2143R/December 2010 15 of 15