Aviva Executive Pension Policy Application Form to Aviva Life & Pensions UK Limited ( Aviva ) Please note carefully This is a legal document and together with the policy conditions (which are available on request) and policy schedule forms part of any subsequent contract with Aviva. All sections must be fully completed and any alterations initialled by the Employer/Trustee signatory / signatories. A copy of the completed application form is available on written request. 1. Checklist of documents to be submitted with this completed application form A fully completed application form A completed Letter of Exchange to establish the Aviva Executive Pension Plan. If applicable, a cheque for the transfer payment made payable to Aviva Life & Pensions UK Limited If you wish to pay by Electronic Funds Transfer (EFT) please quote the application number or the name of the customer. Our details are as follows: Bank: Ulster Bank IBAN: IE26ULSB98501050090570 BIC: ULSBIE2D The employee s most recent P60 or payslip If any of the required items are not submitted with the application form, we will be unable to proceed with the application. Contributions will not be invested in the chosen funds until we have received all of our requirements. 2. Financial Broker Details 1. Agency Number 2. Name of Financial Broker/Company Please complete this form in BLOCK CAPITALS 3. Financial Broker s Email Address 4. Financial Broker s phone telephone 5. Aviva Broker Consultant Name 3. Employer Details Employer s Name Employer s Address Registered Address Employer s Tax Number Telephone Full Name of Company Directors 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 7950 Web www.aviva.ie Registered in England (3253947) at Wellington Row, York, YO90 1WR.
4. Employee Details (a) Personal Details Title Mr Ms Mrs Other First Name Surname Date of Birth / / PPS Please complete parts (a) and (b) Gender Male Female Relationship Status Single Married Separated Divorced Widow(er) Civil Partner Address Contact Telephone Number Email Profession / Occupation Earnings / Salary Is the employee a 5% director Yes No Is the employee a 20% director Yes No Date of entry into service / / Normal Retirement Age 60 65 70 Other (b) Employee s existing pension benefits Does the employee have any pension benefits from current or previous employments? Yes No If No, please proceed to Section 5. If Yes, please supply the details in the relevant areas below or on a separate page if required. (i) Does the employee have defined contribution company scheme pension benefits from current or previous employments? Yes - Current Employment Yes - Previous Employment No If Yes to either provide details: Normal retirement age If current employment Total employer contributions p.a. Name of Life Company Total employee contributions p.a. This must be between the age of 60 and 70. It is important that complete details of benefits from all other pension arrangements are provided below. Revenue will return any applications with missing details and may ask for additional information to grant approval, which can cause delays in getting the policy issued. Include the value of AVCs / Personal Retirement Savings Account (PRSA) AVCs If previous employment Scheme Name Name of Life Company
(ii) Does the employee have Personal Pension / PRSA (including self-employed) pension benefits from current or previous employments? Yes No If Yes provide details Current value Name of Life Company (iii) Does the employee have defined benefit company scheme pension benefits from current or previous employments? Yes - Current Employment Yes - Previous Employment No If Yes to either provide details: Normal retirement age Pension payable at NRA Retirement lump sum (if in addition to pension at NRA) Spouses pension % / Registered civil partners pension % % Current value of any AVC / PRSA AVC If current employment Total employee & AVC contributions p.a. Death benefit p.a. Name of Life Company If previous employment Date of leaving service / / Scheme Name Name of Life Company (iv) Has the employee received benefits from any other pension arrangements? Yes No If Yes provide details Date benefits were paid? / / For Defined Contribution Schemes, PRSA or Personal Pension benefits: Total value of pension fund at date of payment For Defined Benefit / Public Sector Schemes: Gross retirement lump sum (before any tax was paid) Annual pension income Final value of AVCs (if not included in above amounts)
5. Contribution Details for the Aviva Executive Pension Policy Note for Financial Brokers: Please ensure that you complete the Product Details in Section 11 of this application form. Start Date / / Contributions Employer Employee AVC Total Regular Single Transfer The start date must be between the 1st and 28th of the month. Any regular contribution must not be less than 100 per month to set up an Aviva Executive Pension. Any single contribution or transfer payment must not be less than 5,000. Contribution Frequency and Payment Method Monthly Direct Debit Yearly Direct Debit Yearly Cheque Yearly by Electronic Funds Transfer (EFT) Single by Electronic Funds Transfer (EFT) Automatic increase in contribution Source of funds - EFT Please provide details of the bank account from which the funds for the policy were paid unless method of payment is by cheque in the trustee s name. No Automatic Increase in Contribution - Unless you have said No, regular contributions will increase by 5% each year. This will take place on the yearly anniversary date of the policy. Account name Account number IBAN Bank identifier code BIC Transfer Payment Name of Life Office from which transfer payment is received Plan Reference Number Is the transfer payment from an overseas pension plan? Yes No If Yes, from which country does the transfer originate from? Name of the company that acts as insurer / administrator / custodian / manager / trustee of the transferring pension arrangement Transfers cannot originate from the UK. Address of that Company Name of Contact Person of the transferring pension arrangement E-mail address Telephone Number
Overseas Transfer Declaration (only relevant where your transfer is coming from an overseas pension scheme) I wish to transfer the assets of my overseas pension arrangement to the Aviva Executive Pension Plan. I agree to allow Aviva to obtain any information it regards as relevant from the Company and / or Contact Person, named above, in order to facilitate the transfer of my fund. I authorise the Company and / or Contact Person named above to give Aviva any information relevant to this transfer. Signature of Employee
6. Fund Choice - select option (a) or (b) only (a) Fund Choice managed by you / for you Please complete details of the fund choice and the proportion to be invested in each fund. Please note, we can only accept whole percentage numbers. Regular Single AVC Transfer ALL Contribution Contribution Payment Cash Fund % % % % % Bond Fund % % % % % Long Term Bond Fund % % % % % Corporate Bond Fund % % % % % Multi Asset Fund Cautious (Risk 3) % % % % % Multi Asset Fund Strategic (Risk 4) % % % % % Multi Asset Fund Dynamic (Risk 5) % % % % % Aviva Investors Multi-Strategy (AIMS) Target % % % % % Return Fund (Ireland) Merrion Multi Asset 30 % % % % % Merrion Multi Asset 50 % % % % % Merrion Multi Asset 70 % % % % % Irish Property Fund % % % % % UK Property Fund % % % % % High Yield Equity Fund % % % % % Eurozone Equity Income Fund % % % % % Asia Pacific Equity Income Fund % % % % % Emerging Market Equity Income Fund % % % % % Legal & General Investment Management Multi % % % % % Index III Fund Legal & General Investment Management Multi % % % % % Index IV Fund Legal & General Investment Management Multi % % % % % Index V Fund L&G Euro Bond Index Fund % % % % % L&G World Equity Index Fund % % % % % L&G Emerging Markets Equity Index Fund % % % % % L&G Europe (ex. UK) Equity Index Fund % % % % % There is a minimum investment of 10 per fund. Total 100% Please see our Fund Guide, Your Investment Options for full details on all of our funds, and speak to your Financial Broker. (b) Lifestyle Strategy For full details on all the fund options and the Lifestyling strategies available through the Aviva Executive Pension, please see the separate Lifestyle Strategies from Aviva and Your Investment Options brochures and speak to your financial broker. Lifestyling strategies use an automatic system that, over time, switches your pension fund from higher risk funds to lower risk funds as you approach retirement. This in effect means that the pension fund you have built up is gradually de-risked over a set period of time prior to your retirement age. Please select one option below: Aviva Investors Annuity Aviva Investors ARF Legal & General Annuity Legal & General ARF Merrion Annuity Merrion ARF
7. 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 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 this application not proceeding or the 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 the Employee confirm, by signing the declaration in Section 8, and you the Employer/Trustee 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. 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. 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. This Data Protection Notice should be read by the Employee as well as by the Employer/Trustee. This marketing opt out tick box is for completion by the Employer/Trustee.
8. Employee Authorisation and Declaration I authorise the deduction of the contribution specified in Section 5 from my remuneration (if applicable). I consent to my employer, the trustee of the Aviva Executive Pension Plan and/or Aviva verbally or otherwise, seeking and receiving such additional information as they may require for the purposes of this application, the policy or the Aviva Executive Pension Plan and I hereby authorise my employers and previous employers, the trustees, administrators and life assurance providers of relevant pension arrangements and my agents to provide such information to my employer, the trustee of the Aviva Executive Pension Plan and/or Aviva. I am resident for tax purposes in the Republic of Ireland and have an address in the Republic of Ireland. I undertake to inform Aviva of any change in my country of residence during the life of the policy. I agree to the use by Aviva of all information and personal data disclosed by me or on my behalf in connection with this policy, including where applicable, sensitive personal data, as indicated in the Data Protection Use of Information Notice in Section 7. Employee Signature Please sign and date Date / / 9. Employer/ Trustee Declaration We apply to Aviva for this Aviva Executive Pension Policy to be issued to us as trustee/s of the Aviva Executive Pension Plan established by the Letter of Exchange and declare that: 1. The information in this application for this policy above is true and complete to the best of our knowledge and belief. 2. We understand that the policy is conditional on the approval of the Aviva Executive Pension Plan by the Revenue Commissioners as an exempt approved scheme under Chapter 1 of Part 30 of the Taxes Consolidation Act, 1997. 3. We confirm that the contract effected in pursuance of this application will be held by us as trustees under irrevocable trust for the purpose of providing retirement and other relevant benefits as defined by Chapter 1, Part 30 of the Taxes Consolidation Act 1997 to or in respect of the employee as set out in the Aviva Executive Pension Plan Rules referred to in the Letter of Exchange. 4. We consent to Aviva, verbally or otherwise, seeking and receiving additional information 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 and I/we hereby authorise the trustees, administrators and life assurance providers of relevant pension arrangements with information relevant to this application and our agents to provide such information to Aviva. 5. We agree that without further communication to us Aviva may, if they accept this application, issue a policy comprising policy conditions on Aviva s standard terms for policies of this type (a copy of which has been made available) and a policy schedule as regards the particulars of the policy such as the contribution amounts, fund choices and charges. 6. We agree that the policy conditions and policy schedule together with this application will form the contract between Aviva and us as trustees. 7. We agree and understand that even if a contribution is tendered or direct debit mandate is signed, no binding contract is created until Aviva has issued the policy. 8. We are resident for tax purposes in the Republic of Ireland and have an address in the Republic of Ireland. We undertake to inform Aviva of any change in our country of residence during the life of the policy. This must be completed in all cases where the employer is the trustee or where an independent trustee has been appointed.
9. We appoint Aviva to act as registered administrator of the Aviva Executive Pension Plan under Section 59 of Part VI of the Pensions Act, 1990 as amended, and we understand that by accepting this application, Aviva agrees to act as such. We agree that either Aviva or the trustees can choose to terminate this appointment by giving at least 90 days written notice to the other party. This 90 day notice period may only be reduced where both parties agree to it, or if required by legislation. 10. We agree and understand that Aviva s processes may involve electronic means including, but not limited to, data entered online, the capturing of our 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. 11. We agree to the use by Aviva of all information and personal data disclosed by us or on our behalf in connection with this policy, including where applicable, sensitive personal data, as indicated in the Data Protection Use of Information Notice in Section 7. Signature Duly authorised to sign for and on behalf of the Employer and Trustee. Name of authorised person Please sign and date Position in the company Date / /
10. Letter of Exchange By completing the Letter of Exchange the employer sets the pension scheme up in trust for the employee. Between And Employer Employee Date / / The Employer now establishes under irrevocable trusts an Aviva Executive Pension Plan, ( the Plan ), which is a retirement benefits scheme capable of being approved ( Approved ) by the Revenue Commissioners as an exempt approved scheme under Part 30, Chapter 1, Taxes Consolidation Act 1997, for the purpose of providing relevant benefits in respect of you. The Plan is governed by this letter and the Rules in the form of the standard Aviva Executive Pension Plan Rules ( the Rules ) which are contained in your Member Pack (and in the meantime are available to you on request), and are hereby adopted. The Plan commences on the Start Date specified in the Rules. On the Start Date the Plan benefits will be provided by policy/policies of assurance issued to the Employer as Trustee by Aviva in accordance with the application (to which this letter is attached) and any subsequent supplementary applications to Aviva. You will receive a member s explanatory booklet which will give you an overview of the Plan and documents called a Member Pack which will identify benefit and contribution particulars of the Plan in respect of you. As required by the Employer or as agreed between you and the Employer, subject to the Rules, the contributions payable to the policy/policies of assurance will be contributed by the Employer and you may be required to contribute and/or you may contribute on a voluntary basis. The Employer with the consent of the Trustees (if the Employer is not the sole trustee) may from time to time in writing, delete, replace or supplement all or any of the provisions of this letter and/or the Rules and any such amendment, deletion, replacement or supplementation may have effect from such time as may be specified including any time previous or subsequent thereto provided that no such amendment, deletion, replacement or supplementation shall be made which would result in the Plan ceasing to be Approved. Please agree to this letter and the Rules by signing below. Signature of person duly authorised to sign for and on behalf of the Employer Please sign and date Name of authorised person Position in the company I acknowledge receipt of this letter and understand the contents thereof. I hereby agree to be included in the scheme. Employee Signature Please sign and date
11. Product Details (To be completed by Financial Brokers) (a) Aviva Executive Pension Range 1 Regular Contributions Product code Please specify the % of contribution commission: Product Codes can be found in Pensions from Aviva - Financial broker Booklet % Note: this can range from Nil to 5% in bands of 0.25%. Single Contribution Product code Please specify the % of contribution commission: % Note: this can range from Nil to 5% in bands of 0.25%. Transfer Payments Product code Please specify the % of contribution commission: % Note: this can range from Nil to 5% in bands of 0.25%. Fund Based Commission Please specify the % of contribution commission: % Note: this is available in bands of 0.05% up to 0.50% and then in bands of 0.25% from 0.50% to 1.00%. (b) Aviva Executive Pension Range 2 Regular Contributions Product code Please specify the following: Initial Commission % Renewal Commission % Single Contribution Product code Please specify the % of contribution commission: % Note: this can range from Nil to 5% in bands of 0.25%. Regular Contributions Initial commission is a maximum of 15% (based on 1.25% x term to a maximum retirement age of 68). Renewal commission can be between 0% and 4%. Transfer Payments Product code Please specify the % of contribution commission: % Note: this can range from Nil to 5% in bands of 0.25%. Fund Based Commission Please specify the % of contribution commission: % Note: this is available in bands of 0.05% up to 0.50% and then in bands of 0.25% from 0.50% to 1.00%. (c) Aviva Executive Pension Range 3 Regular Contributions only Please specify the following: Bullet commission: % Product code Bullet commission: Please specify either 30% or 40%. Fund Based Commission Please specify the % of contribution commission: % Note: this is available in bands of 0.05% up to 0.50% and then in bands of 0.25% from 0.50% to 1.00%
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* Date 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 7950 Web www.aviva.ie Registered in England (3253947) at Wellington Row, York, YO90 1WR. 6.35.01.18