Regular Saver Before completing this form, please read the Regular Saver 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. Evidence of PPS Number (one of below) P60 P45 P21 Payslip (where employer is identified by name or tax number) Social Services card Tax Assessment Tax Return Form One copy of Photo ID per policy owner (one of below) A current passport, A current drivers licence, A current national identity card, An ML10 form with photo certified by a member of An Garda Síochána One Copy of address verification per owner (one of below)* 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, A house or motor insurance certificate, A local authority bill, A court document, such as a Grant of Probate, or A TV licence renewal 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 or a Direct Debit Mandate from applicant s bank account in which case bank account details are not required. Where has the money come from (Source of Wealth) Please see section 4 for full details. Income & Occupation This is to confirm your job and your current salary
Plan basis Single life Joint life 1. Personal Details First Life Insured Title Forename Second Life Insured Title Forename Surname Surname Present Address Present Address Telephone Email Please include your email address for Aviva online access Occupation of Birth Telephone Email Please include your email address for Aviva online access Occupation of Birth 2. Policyowner(s) (if different) First Policy Owner (if applicable) Title Forename Second Policy Owner (if applicable) Title Forename Surname Surname Present Address Present Address Telephone Email Occupation of Birth Relationship to lives assured (or details of insurable interest) Telephone Email Occupation of Birth Relationship to lives assured (or details of insurable interest) 3. Investment Details Option A Minimum Monthly Payment 100 Option B Minimum Monthly Payment 500 Start Regular Payment Single Payment Minimum Single Payment 5,400 (Please Note: All payments are inclusive of the Government Levy). Monthly payments can only be made by direct debit. Is your Regular Saver to be written in trust? Yes No If yes, please enclose completed Trust form. Indexation @ 5% p.a. or CPI Yes No (whichever is greater) Would you like to invest your lump sum in different funds to your regular payments Yes No Fund Choice for your Regular Payments Percentage Fund Choice for your Lump Sum Percentage % % % % % % % % 100% 100%
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. Anti-Money Laundering Requirements As part of our Anti-Money Laundering requirements, Aviva is obliged to obtain certain documents and information about you to confirm (1) your identification and address (2) your income and the origin of the funds you are investing with us and (3) the method of payment being used. Photo ID and address verification attached 1st Policy Owner 2nd Policy Owner Please note that this is required for each policyholder. Please indicate Source of Wealth and Source of Funds for your regular contributions (R.C.) and single contributions ( S.C.) if any. Source of Wealth 1st Policy Owner Source of Wealth 2nd Policy Owner Please state your total annual gross income (i.e. salary and other income) Please advise the origin of the funds being invested R.C. S.C. Salary Early retirement or redundancy payment Sale of Investment Regular Savings Inheritance Reinvestment Aviva policy Reinvestment external policy Other (Please specify) Aviva reinvestment policy number (if relevant) Please state your total annual gross income (i.e. salary and other income) Please advise the origin of the funds being invested R.C. S.C. Salary Early retirement or redundancy payment Sale of Investment Regular Savings Inheritance Reinvestment Aviva policy Reinvestment external policy Other (Please specify) Aviva reinvestment policy number (if relevant) Source of Funds 1st Policy Owner Please advise the method of payment of the funds being invested. R.C. S.C. Personal Cheque from applicant s bank account Direct Debit Mandate from applicant s bank account EFT Encashment / Maturity proceeds of an Aviva policy Encashment / Maturity proceeds of external policy Other (Please specify) Source of Funds 2nd Policy Owner Please advise the method of payment of the funds being invested. R.C. S.C. Personal Cheque from applicant s bank account Direct Debit Mandate from applicant s bank account EFT Encashment / Maturity proceeds of an Aviva policy Encashment / Maturity proceeds of external policy Other (Please specify) Unless method of payment is personal cheque or a Direct Debit Mandate from the applicant s bank account, please provide details of the bank account from which the funds for the policy were paid. 1st Policy Owner Account Name Account number IBAN Bank identifier code BIC 2nd Policy Owner Account Name Account number IBAN Bank identifier code BIC
5. Tax Residency This section 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 1st Policy Owner Are you resident for tax purposes anywhere other than the Republic of Ireland? Yes No (If you are a US Citizen or hold a US passport or green card, you will be considered tax resident in the US even if you live outside the US, so you must answer Yes ) If yes, please provide your Tax Identification/Reference Number and country/countries of tax residency. If you are tax resident in more than one country, please detail all countries of tax residency and associated Tax Identification Number. Country/countries of tax residency Tax Identification / Reference Number If you have no reference number please explain why 2nd Policy Owner Are you resident for tax purposes anywhere other than the Republic of Ireland? Yes No (If you are a US Citizen or hold a US passport or green card, you will be considered tax resident in the US even if you live outside the US, so you must answer Yes ) If yes, please provide your Tax Identification/Reference Number and country/countries of tax residency. If you are tax resident in more than one country, please detail all countries of tax residency and associated Tax Identification Number. Country/countries of tax residency Tax Identification / Reference Number If you have no reference number please explain why If you need to provide further details, please include them on an additional sheet of paper. 6. PPS number Please ensure documentary evidence is supplied as verification of the tax number provided. Please provide PPS number Policy Owner 1 Policy Owner 2 7. Declaration 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 Name of insurer or insurance intermediary
Declaration of Client(s) I/We declare that the said statements and answers in this application shall be the basis of the contract and understand that if any premium is tendered, no binding contract is created until Aviva Life & Pensions UK Limited has received and accepted the application and investment. I/We confirm that I/we have received in writing the information specified in the above insurer or intermediary declaration. I/We agree to the use by Aviva Life & Pensions UK Limited of my/our personal data and where applicable, sensitive personal data, as indicated in the Data Protection Use of Information Notice in section 8. Signature 1st Life Insured Signature 2nd Life Insured Policyholder(s) (if different from above): Signature 1st Policy Owner Signature 2nd Policy Owner 8. 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. 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). From time to time, we may record your telephone calls for quality assurance purposes. You may request, in writing, a copy of your information held by us. Please write to the The Compliance Manager 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 Compliance Manager 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 7, 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. 9. For Financial Adviser use only Please ensure all relevant questions are answered before submitting the application form. Name Address Financial Adviser No. Name of Salesperson Salesperson Reg. No. (LARC) Special Instructions For office use only Consultant Branch
Application No. SEPA DIRECT DEBIT MANDATE SEPA Direct Debit Mandate Unique Mandate Reference (UMR) To be completed by Aviva Life & Pensions UK Limited By signing this mandate form, you authorise (A) Aviva Life & Pensions UK Limited to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Aviva Life & Pensions UK Limited. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that can be obtained from your bank. Please complete all fields marked* Name(s) of Account holder(s) * Account number IBAN* Bank identifier code BIC* Creditor s name Aviva Life & Pensions UK Limited Creditor identifier I E 7 4 Z Z Z 9 9 2 9 5 0 Creditor address One Park Place, Hatch Street, Dublin 2, Ireland. This mandate is in respect of a recurring payment. x x Signature* Signature* D D M M Y Y Y Y Location Please return this mandate to Aviva Life & Pensions UK Limited trading as Aviva Life & Pensions Ireland, One Park Place, Hatch Street, Dublin 2. Please note: Banks may refuse to accept instructions to pay Direct Debits from some types of accounts, usually savings or deposit accounts. If in doubt check with your bank. Aviva Life & Pensions UK Limited may combine the Direct Debits for this mandate with those from any other mandate(s) which you have signed in their favour and which may be payable to them within the same calendar month. Payment amounts may vary from time to time.
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. 1.310.04.16