ADDING OR AMENDING CONTRIBUTIONS

ADDING OR AMENDING CONTRIBUTIONS to your Pension (PP1-4, PPS, FS1-4) We try not to use technical jargon but where this is unavoidable we have explained the meanings in a glossary at the end of the form. With this form you can: add or amend regular contributions make an additional single contribution into a Personal Pension (PP1-4 and PPS) or a Free Standing Pension (FS1-4). There is a separate form for making transfers in from other pension arrangements. All references to Old Mutual Wealth in this application mean Old Mutual Wealth Life Assurance Limited. We recommend that you complete this form with help from your financial adviser. If you don t have an adviser and would like to find one in your area, you can find a range of options by visiting www.oldmutualwealth.co.uk/find-an-adviser. Please tick/complete this form using BLOCK CAPITALS and blue or black ink, initialling any amendments or corrections. uif you are under 16 or between 16 and 18 and not in employment, this application must be completed by your legal guardian. Failure to answer the following question will delay your application Have you been given advice about this application by your financial adviser? Yes No A YOUR DETAILS Your plan number u your plan number will begin with PP or FS Your full name Permanent residential address (c/o addresses are not acceptable) uif your address is different from the one we have on our records or it has changed within the last 12 months, we will need proof of the new address, for instance a recent original bill showing the new address, eg phone, electricity, gas, water, etc but not a mobile phone bill. Date of birth National Insurance Number Contact details Tel: Email: B LEGAL GUARDIAN S DETAILS (if applicable) Full name Permanent residential address (c/o addresses are not acceptable) Contact details Tel: Email: 1 of 8

C CONTRIBUTIONS Complete this section with details of the contributions for your pension. Please note you could suffer a tax liability if contributions are funded from a tax-free cash sum received from a registered pension scheme. Employer contributions cannot be paid into free-standing (FS) pensions. Employer s contribution (gross) (including any contribution being made by salary sacrifice) Your contribution (net) Total Single contribution Minimum additional single contribution 500 gross. Your employer must complete section J If being paid by a third party, complete section D Employer s contribution (gross) (including any contribution being made by salary sacrifice) Your contribution (net) Total Regular contribution Your employer must complete section J If being paid by a third party, complete section D Frequency of regular contributions Monthly Yearly The start date for your regular contribution, or for the amended regular contribution, will be the first of the next available month. If you would like a later start date, please state the month and year required here: 0 1 M M 2 0 Y Y u this cannot be back-dated If you are adding regular contributions for the first time and you want the amount to be automatically increased at each annual review, tick here u the increase will normally be the greater of 10% or the rate of inflation. The Direct Debit Instruction at the end of this form is required where a regular contribution is being added for the first time, or where the payer s bank details have changed. d THIRD PARTY PAYER DETAILS (if applicable) Complete this section with details of any third party (other than your employer) paying your contributions. The data may be made available to a third party for the purpose of verifying the identity in accordance with Money Laundering Regulations. In some circumstances the plan owner may be the only person permitted to pay premiums. Please contact Old Mutual Wealth if you have any queries about this. Full name(s) of the third party Permanent UK residential address Date of birth Contact number Which contribution is being paid by this third party? Single Regular u in case of query E Money Purchase Annual Allowance You do not need to complete this section if you have already provided the information to Old Mutual Wealth. Have you taken any benefits from any pension arrangements with Old Mutual Wealth or any other pension provider, in a way that means you are subject to the Money Purchase Annual Allowance (MPAA) which limits the total contributions that can be paid to money purchase registered pension schemes to 4,000 a year? Yes No If Yes please confirm the date on which the MPAA first applied to you 2 of 8

F INCREASED PROTECTION BENEFITS (if applicable) If you have incapacity benefit and/or life cover You can increase these benefits in line with any increases to your regular contributions (up to a maximum of 10% in any rolling 12-month period). If required, tick the following (as applicable): I have incapacity benefit and want to increase it in line with increases to my regular contributions (up to a maximum of 10%) u payment will be capped as detailed in your Member s Guide I have life cover and want to increase it in line with increases to my contributions (up to a maximum of 10%) If you have waiver of contribution benefit Have contributions to your pension (including those in this form) increased by more than 10% in the last 12 months? No We will automatically increase your waiver of contribution benefit in line with any increases to your regular contributions Yes Tick one of the following to indicate how you want us to proceed: u if neither is ticked it will delay your instruction while we contact you for clarification continue with the increase and remove the waiver of contribution benefit u once the waiver of contribution benefit is removed, we cannot reinstate it limit your contribution increase to the maximum allowed, and keep the waiver of contribution benefit on your plan Any protection benefits chosen are guaranteed to remain in force for one year between review dates, provided regular contributions continue at least at the level required. G FUND CHOICE Amended regular contributions Tick here if your fund choice for the amended contribution is the same as your current regular contribution fund choice, Now go to section H OR Complete the table below to select different fund(s) for your amended contributions Single/New regular contributions Tick here if your fund choice is the same as for your regular contributions Now go to section H OR Complete the table below to select your fund(s) for your single/regular contributions If your fund choice is incomplete or otherwise invalid, we will allocate part or all of the investment as appropriate to the OMW Deposit Fund. We are not authorised to provide advice; your financial adviser will be able to help you choose the funds most suitable for you. You can choose up to 99 funds if there is insufficient space for you to list all of your chosen funds below, continue on a separate sheet and attach it to this application. Any Portfolio Rebalancing currently in place will be cancelled as a result of this application; we will need a new Portfolio Rebalancing instruction if you want this service to continue. Fund manager Full fund name Whole % (minimum 1%) Total 100% 3 of 8

H PAYMENTS TO YOUR FINANCIAL ADVISER If you HAVE been given advice about this application by your financial adviser: Go to section I uno commission or fees will be paid from your plan for this transaction. Any fees you agree to pay your financial adviser for the advice received will need to be arranged separately. If you HAVE NOT been given advice about this application by your financial adviser: Do you wish commission to be paid to your financial adviser for this transaction? NO Go to section I The rates of commission shown are the maximum rates payable (and exclude any Marketing Allowance that may be payable). If you do not require maximum initial commission, please state the rate or amount required. We do not pay remuneration to financial advisers for plans opened in their own names. Financial advisers should refer to our Terms of Business for further information. TABLE 1 REGULAR CONTRIBUTIONS Plan numbers starting with: Option 1 Option 2 Option 3 Option 4 PPS, PP1, PP2, FS1, FS2, PP3, FS3 (pre CMD) Up to 25% initial commission PP3, FS3 (post CMD*) Zero or 5.75% initial commission Zero or 4.85% initial commission + 0.25% pa fund-based commission Zero or 4% initial commission + 0.50% pa fund-based commission PP4, FS4 (pre CMD*) Up to 12.5% initial commission PP4, FS4 (post CMD*) Zero or 3.6% initial commission Zero or 2.25% initial commission + 0.50% pa fund-based commission Please complete ONE of the following: Option 1. % or Option 2 Commission to be paid on the same basis as the existing level Option 3 Commission to be paid on the same basis as the existing level (plus fund-based commission each year as stated) Option 4 Commission to be paid on the same basis as the existing level (plus fund-based commission each year as stated) * CMD is the Charge Maturity Date. It can be at any point between the commencement date of the plan and the selected retirement age. Call us if you want more information or to find out your Charge Maturity Date. TABLE 2 SINGLE CONTRIBUTIONS Plan numbers starting with: Option 1 Option 2 Option 3 PP1, PPS, FS1 PP2, PP3, PP4 FS2, FS3, FS4 Up to 4% initial commission Up to 3.10% initial commission + 0.25% pa fund-based commission Up to 2.25% initial commission + 0.50% pa fund-based commission Please complete ONE of the following: Option 1. % or Option 2. % or Option 3. % or 4 of 8

I YOUR Declaration Any omission or misstatement of a material fact in this application form could affect the payment of benefits under the arrangements comprising the Personal/Free Standing 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 request that the changes detailed in this application are made to my existing plan. b) I understand that the Personal Pension will comprise a single arrangement in respect of any regular or single contributions paid by me or on my behalf by my employer or a third party and any transfer payments. c) I declare that to the best of my knowledge and belief the statements made in this application and declaration and any related documents are correct and complete and that I have not concealed any material fact. d) I declare that the total contributions paid by me or on my behalf to any registered pension scheme on which I am entitled to tax relief, do not exceed any of the following: the higher of the basic amount ( 3,600), or my relevant UK earnings for the tax year. e) I agree to supply information relevant to the Personal Pension as shall be required by Old Mutual Wealth from time to time. f) I undertake to notify the Scheme Administrator immediately if the total contributions paid by me or on my behalf to any UK-registered pension scheme on which I am entitled to tax relief do exceed the higher of the basic amount ( 3,600) or my relevant UK earnings for the tax year or if I cease to be entitled to relief at source on my contributions. I will give notice of this by the later of: i) 5 April in the year of assessment in which the event occurs; and ii) the date which is 30 days after the occurrence of that event. g) I declare that contributions made to the Plan have not been and will not be funded from a tax-free cash sum from a registered pension scheme to the extent that either myself nor Old Mutual Wealth will suffer a tax liability. h) I declare that any person paying contributions as a third party has been made aware and accepts that they have no claim to benefits arising from my membership of this pension scheme. i) If Portfolio Rebalancing applies to my plan, I understand that: i) my instructions will automatically be cancelled as a result of this application. ii) new Portfolio Rebalancing instructions will be required should I wish to reinstate the service. Legal guardian declaration a) I understand the contributions paid to the plan 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 plan until the member reaches 18. c) I declare that I will be responsible for ensuring that contribution limits in respect of the minor are not exceeded. d) I agree to advise Old Mutual Wealth of the National Insurance number of the minor when they reach age 16. Personal Data Statement I agree that you may keep and use my personal data to process my application and to service my plan. I confirm that each beneficiary and/or my spouse or civil partner or dependant referred to in this application (or parent where parental consent is required if a beneficiary is a dependant) consents and agrees to my acting as their agent for the purposes of the personal data provided within the application being returned to you for the administration of my plan. I understand that you may provide my personal data, by electronic or other means, to: other companies within the Old Mutual plc group of companies if you regard this as necessary to service my plan my financial adviser including via a secure restricted access internet service my employer/trustee/administrators of the scheme (where applicable) a third party to verify my identity in line with money laundering or other requirements re-insurers and other third parties who perform tasks for you to help you to service my plan. These third parties may be based in countries outside the EEA. These countries may not have laws to protect data equivalent to those in 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. investigate or prevent fraud. I understand that to prevent and detect fraud you may: share my personal data with other organisations including the police check and/or file my personal data with fraud prevention agencies and databases and if I give you false or inaccurate information and you suspect fraud you will record this. I understand that: Old Mutual Wealth and the Old Mutual plc group of companies may use my data for assessment and statistical analysis purposes and without identifying me make results available to third parties. my personal data may be made available to third parties where required by law, court order or regulation. on payment of a small fee I am entitled to receive a copy of the personal data that you hold on me and that I have the right to require you to correct any inaccuracies. Continued 5 of 8

I YOUR Declaration (continued) THIS FORM ACTS AS AN APPLICATION FOR TAX RELIEF AT SOURCE ON YOUR CONTRIBUTIONS. IT IS THEREFORE A SERIOUS OFFENCE TO MAKE A FALSE STATEMENT. THE PENALTIES ARE SEVERE AND COULD LEAD TO PROSECUTION. Your signature Date D D M M 2 0 Y Y Legal guardian s signature u if 16 or over Date D D M M 2 0 Y Y urequired if the applicant is under 18; even if he or she has signed above. Your employer must complete section J overleaf if contributing to your pension J EMPLOYER S DECLARATION to be completed by your employer The statements in this form are correct to the best of our knowledge and belief. u please tell us if any of your details have changed Employer s name Employer s address Signed Date D D M M 2 0 Y Y on behalf of the employer named above Capacity u this must be an authorised official GLOSSARY Fund-based commission This is ongoing commission we pay to your financial adviser, payable monthly, quarterly or half-yearly. It is calculated as a percentage of the encashment value of your plan each year. Initial commission This is commission we pay your financial adviser at the start of your plan, or when contributions are made. You can agree a different level each time you make a single contribution. Marketing allowance This is an enhancement to the initial commission we pay to your adviser. Different advisers have different rates of Marketing Allowance. Salary Sacrifice If your contributions are paid through salary sacrifice, it means you have given up part of your paid salary and that amount is paid into your pension. Send the completed form and direct debit instruction (if applicable), to: Old Mutual Wealth Old Mutual House Portland Terrace Southampton SO14 7AY Customer Contact Centre Tel: 0808 171 2600 6 of 8

DIRECT DEBIT INSTRUCTION Please complete and return this form to authorise us to collect Direct Debits for your plan. We can only accept one Direct Debit instruction on a plan. Direct Debit collections will be made on the first working day of the month. They will show on your bank statement as Old Mutual Wealth Life Assurance limited. Please complete the details below in BLOCK CAPITALS with blue or black ink. We will insert the Reference on the Direct Debit instruction; please leave this blank. Send the completed form to us at the address shown below; do not send it direct to your bank. The instruction below must be signed in accordance with the authorised signature(s) for the bank account. Instruction to your bank or building society to pay by Direct Debit. Please complete the form and send to: Old Mutual Wealth Life Assurance Limited, Old Mutual House, Portland Terrace, Southampton SO14 7AY. Name and full postal address of bank/building society Service user number 9 9 5 3 0 1 Reference To: The Manager B Address bank/building society Instruction to your bank or building society Please pay Old Mutual Wealth Life Assurance Limited Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Old Mutual Wealth Life Assurance Limited and, if so, details will be passed electronically to my bank/building society. Name(s) of account holder(s) Signature(s) Date / / / / Bank/building society account number Branch sort code - - Banks and building societies may not accept Direct Debit Instructions for some types of account. This Guarantee should be detached and retained by the payer. The Direct Debit Guarantee. This Guarantee is offered by all banks and building societies that accept Instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Old Mutual Wealth Life Assurance Limited will notify you five working days in advance of your account being debited or as otherwise agreed. If you request Old Mutual Wealth Life Assurance Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by Old Mutual Wealth Life Assurance Limited or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when Old Mutual Wealth Life Assurance Limited asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. 7 of 8

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. 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. 8 of 8