Powered by Wealth Interactive Data capture for the International SELECT Bond For individual, joint, individual trustee and joint trustee investors This form is to gather the necessary information to input new business online for the product mentioned above on Wealth Interactive. This form in not an application form and will not be accepted as such if sent to us. You must submit this information online. Some of the information required is compulsory and is denoted by *. If any of this information is missing, you will not be able to complete the online process. Items preceded by # denote information that is dependent on the options that have been selected and will not be required in all cases. There are two stages on Wealth Interactive: Creating a new client Creating a new investment (opening an account). Information required to Create a new client 1 Details of applicant Applicant 1 *Nationality *Country of residence Dual Nationality (if any) *Correspondence language * Old Mutual International Old Mutual International Isle of Man Isle of Man company providing the product (select from the drop-down list) *Assigned Adviser *Title Mr Mrs Miss Other *First name Middle name(s) *Surname Previous name/alias (if any) *Sex Male Female * Date of birth identificaton details *ID Type *ID Country of issue Town of birth (can be Passport or National Identity Card) *ID Number * ID Expiry date (only if passport used) 1 of 9
1 Details of applicant (CONTINUED) Applicant 2 (if any) *Nationality *Country of residence Dual Nationality (if any) *Correspondence language * Old Mutual International Old Mutual International Isle of Man Isle of Man company providing the product (select from the drop-down list) *Assigned Adviser *Title Mr Mrs Miss Other *First name Middle name(s) *Surname Previous name/alias (if any) *Sex Male Female * Date of birth identificaton details *ID Type *ID Country of issue Town of birth (can be Passport or National Identity Card) *ID Number * ID Expiry date (only if passport used) 2 of 9
2 address and contact details Applicant 1 *Residential address Correspondence address New correspondence address * Same as residential address * Care of adviser *New correspondence address (# Full address plus postcode and country required) Client s contact details (please ensure you provide the country dialling code) Telephone number Mobile number Fax number *Email address Employment details *Please indicate the client s employment status: Employment status Employed Self employed Retired t employed Where your client is employed, self employed or retired (please give details of previous employer), please note: *Occupation *Employer s name/ Own company *Employer s address (full address) *Country salary information * Annual salary or last known salary: #Bonus (if any) Currency Currency taxation details * Country of residence for taxation *Tax reference/national insurance number 3 of 9
2 address and contact details (CONTINUED) Applicant 2 (if any) *Residential address Correspondence address New correspondence address * Same as residential address * Care of adviser *New correspondence address (# Full address plus postcode and country required) Client s contact details (please ensure you provide the country dialling code) Telephone number Mobile number Fax number *Email address Employment details *Please indicate the client s employment status: Employment status Employed Self employed Retired t employed Where your client is employed, self employed or retired (please give details of previous employer), please note: *Occupation *Employer s name/ Own company *Employer s address (full address) *Country salary information * Annual salary or last known salary: #Bonus (if any) Currency Currency taxation details * Country of residence for taxation *Tax reference/national insurance number 4 of 9
3 create new investment (opening an account) *Ownership type (choose from) Single applicant Joint applicant Single trustee applicant Joint trustee applicant policy preferences *Assigned adviser *Product International Select Bond Life Redemption Policy currency GBP Euro US Dollar Tier Selection WealthSelect SelfSelect premium *Lump sum amount GBP Euro US Dollar Phased Investment Entire amount Phased Investment Term 3 6 12 18 24 months Charge Package Do you want an Initial Fee to be facilitated on this premium? Fee type Percentage Facilitated Initial Fee Before investment After investment Ongoing Service Fee monetary amount or % of annual portfolio bond fund Ongoing Service Fee Percentage NOTE You will also need to complete the Financial and Fund Adviser fees authorisation form and upload this as part of the online application process. 5 of 9
3 create new investment (opening an account) continued A) PHASED INVESTMENT OPTION Feeder FUND (Please note, the feeder fund can not be changed once selected). ASSET IDENTIFIER ISIN ASSET NAME IN FULL BASE CURRENCY OF SECURITY/FUND target FUND(S) ASSET IDENTIFIER ISIN ASSET NAME IN FULL BASE CURRENCY OF SECURITY/FUND INVESTMENT % (whole numbers) TOTAL OF PHASED INVESTMENT 1 0 0 B) non-phased investment option #Portfolio Name ASSET IDENTIFIER ISIN ASSET NAME IN FULL BASE CURRENCY OF SECURITY/FUND INVESTMENT % (whole numbers) total 1 0 0 6 of 9
application details *Country of advice Number of policies (default will be 100) Fund/Investment adviser appointment Is the assigned adviser also the Fund/Investment adviser? What is the basis of the fund/investment advice? Discretionary n-discretionary You will be able to enter a fund adviser payment fixed amount or the default percentage will be set at 0%. 3 3 REGULAR WITHDRAWALS Withdrawal type: Percentage : Percentage % # Frequency: Monthly Quarterly Four Monthly Half-Yearly Yearly # Withdraw from (*): #Asset with largest value OR # Proportional sale of assets OR # Specify the asset(s) Asset name % of each asset for regular withdrawal Total 100% Would you like your withdrawals to be made to the same bank account detailed on page 9 payment method? If, please complete the section below. Name as stated on bank account Sort code (If applicable) Bank account number/ IBAN SWIFT or BIC code (If applicable) Bank name Bank s full address Country Postcode 7 of 9
lives assured (THIS INFORMATION IS NOT REQUIRED FOR REDEMPTION BONDS) *Is the policyholder to be a life assured? # If, please detail name and address of the additional life assured. If there is more than one additional life assured, we will need the same information for each person. #Title Life assured 1 Life assured 2 #First name #Middle name(s) #Surname # Residential address, including postcode and country: Postcode Postcode * Nationality charge deduction ASSET - MANDATORY COMPLETION # Take charge proportionally across all assets: OR # Take charge from largest asset: OR # Specify the asset: Asset name 8 of 9
4 payment details/enter payment details of source of premium When applying online, please use the bank details below: BANKING DETAILS Sterling payments From UK banks (CHAPS payments) Sort code: 55-91-00 Bank: Isle of Man Bank, East Region, 2 Athol Street, Douglas, Isle of Man Beneficiary: Old Mutual International Isle of Man Limited Account number : 10939946 From non-uk banks (SWIFT payments) SWIFT code: RBOSIMD2XXX Sort code: 55-91-00 Bank: Isle of Man Bank, East Region, 2 Athol Street, Douglas, Isle of Man Beneficiary: Old Mutual International Isle of Man Limited IBAN: GB94NWBK55910010939946 Other currency payments (SWIFT payments) Payments should be made to Old Mutual International Isle of Man Limited s accounts held with National Westminster Bank, London. SWIFT code: NWBKGB2LXXX Bank: National Westminster Bank, London IBAN: (select as applicable, see below) 1. US dollar IBAN GB05NWBK60730167544800 2. Euro IBAN GB63NWBK60720267545858 payment method Bank details UK Sort Code Account number IBAN SWIFT or BIC Code origin of wealth (Please note that you will have to state the address, value, proceeds of any compensation, competition or gambling win, gift, inheritance, investments/ savings, loan, maturing investments/policy claim/replacement policy, other unearned income, sale of interest in company, sales of property, sale of shares as well as the bank details if the money is coming from savings, and the length of time the money has been held) * Where did the money come from? * Date the money was received *Total amount The total contribution can be made up from a number of Origin of Wealth sources. *Documents to be uploaded You will need to upload a certified scanned copy of the proof of identification and proof of residency. www.oldmutualinternational.com Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Old Mutual International Isle of Man Limited is registered in the Isle of Man under number 24916C. Registered and Head Office: King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0)1624 655 555 Fax: +44 (0)1624 611 715. Licensed by the Isle of Man Financial Services Authority. Old Mutual International Isle of Man Limited is a member of the Association of International Life Offices. Old Mutual International is registered in the Isle of Man as a business name of Old Mutual International Isle of Man Limited. PDF13411/INT17-0175/March 2017 9 of 9