SCOTTISH WIDOWS ANNUITY

SCOTTISH WIDOWS ANNUITY APPLICATION FORM FOR INTERNAL USE SW Policy No. Scottish Widows Quotation No. This application is for the purchase of a Scottish Widows Annuity. The minimum amount we will accept to buy a Scottish Widows Annuity is 3,750 (after any tax-free cash). Please write in BLOCK LETTERS and tick the boxes which apply to you. You (the annuitant) must fill in sections A, B and E. Also section F if you have been offered advice. If a dependant s income is being provided, please fill in section C. You must read and complete Declaration G for an OMO, or Declaration H for a transfer. You must also complete the Lifetime Allowance declaration in section I for a transfer. Your current provider should complete section D. Please refer to section D for guidance. WARNINGS a) This contract cannot accept an earmarking order as a result of divorce proceedings. b) For an Open Market Option (OMO): any tax free cash must be paid by the current provider. only one source of money can be accepted. we cannot accept any Guaranteed Minimum Pension (GMP), Section 9(2B) rights or final salary benefits accrued after 5 April 1997. c) If you are transferring to our Appropriate Personal Pension Scheme to provide an annuity immediately: if you transfer in final salary benefits, GMP or Section 9(2B) rights, the benefits provided will be in a different form and you will lose any guaranteed benefits. if you are currently entitled to more than 25% tax-free cash or you have a protected pension age this would be lost on transfer. Please speak to your financial adviser before proceeding with the transfer. d) You must not make false statements when filling in this application; it is a serious offence. The penalties are severe and you could be prosecuted. QUOTATION REFERENCE YOUR APPLICATION IS BASED ON: The quotation number can be found on the top right of your Scottish Widows Annuity Quotation. It is important that you agree with the options shown on your quotation as this will be the basis of how your Annuity will be set up. Scottish Widows Annuity Quotation Number: QUOTATION REFERENCE YOUR APPLICATION IS BASED ON: Title Mr Mrs Miss Ms Other (Please specify) First name(s) Surname

CHECKLIST TO BE COMPLETED BY YOUR FINANCIAL ADVISER (IF APPLICABLE) Please tick or complete boxes National Insurance Number provided for Annuitant Correct declaration signed and dated (Declaration in section G for OMO, section H for transfers) For transfer cases, Lifetime Allowance Declaration in Section I signed and dated Bank/Building Society details provided for Annuitant (This is required for both any tax-free cash payment and regular income payment) Sales type (please tick one) Advised Non-Advised If Non-Advised please indicate if commission is payable Yes No If advised please complete Advice type below Advice type (please tick one) Independent Restricted Adviser name Adviser signature Date (DD MM YYYY) AGENCY DETAILS Scottish Widows Agency A Number (This must be completed) Adviser Firm Name Financial Services Reference Number Address Postcode Contact Name Email (Please be aware sending personal details by email is not secure) Telephone Number (Please include STD. code) Facsimile Number 2

Notes to Section A 1) Habitual residence means your permanent residential address. We can only accept applications from a limited number of overseas countries. If you are not resident in the United Kingdom, please speak to your financial adviser or contact us to confirm your eligibility. If this annuity is from an existing Scottish Widows pension policy this restriction does not apply. Notes to Section B and C 1) A birth certificate should be sent to us with this application. Where the name on this application differs from that on the birth certificate, we will require proof of your name change, for example marriage certificates etc. 2) Your National Insurance Number can be found on a payslip or P60, or on a tax return. If you have a National Insurance Number, it is essential that you provide it. Without a National Insurance Number, we are unable to process your application. If you cannot find your National Insurance Number, please phone HM Revenue and Customs National Insurance General Enquiries Helpline 0300 200 3500. 3) We will only set up an income after your death for a person who is dependent on you. The income can be paid only to dependant you choose when you set up the annuity, even if you later divorce or remarry. OFFICE USE ONLY Birth Certificate received Name change certificate received P45 received A. ELIGIBILITY In order to determine whether you are eligible to take out a Scottish Widows Annuity, please provide the following information: Country of habitual residence (see note 1) Nationality B. ABOUT YOU (THE ANNUITANT) If this Annuity is from an existing Scottish Widows pension policy please provide the policy number: 1. Title Mr Mrs Miss Ms Other (Please specify) 2. First name(s) 3. Surname 4. Home address Postcode Telephone number 5. Are you Male Female 6. Marital status Single Married/in a registered civil partnership Separated Divorced/registered civil partnership dissolved Widowed/a surviving registered civil partner 7. Date of birth (see note 1) (DD MM YYYY) 8. National Insurance Number (see note 2) (It is essential that this is completed) 9. Relationship to the Dependant (if applicable) 10. If you are not married or in a civil partnership with the dependant, Yes No please tick to confirm whether they are financially or mutually dependent on you? (see note 3) C. ABOUT YOUR DEPENDANT (IF APPLICABLE) 1. Title Mr Mrs Miss Ms Other (Please specify) 2. First name(s) 3. Surname 4. Date of birth (see note 1) (DD MM YYYY) 3

Notes to Section D 1) The original pension member has died and this annuity is being provided for a dependant of the member. This can only be accepted as an Open Market Option. It is not possible to provide a dependant s income after their death or a guaranteed period and no tax-free cash can be paid. D. ABOUT YOUR CURRENT SCHEME OR POLICY (TO BE COMPLETED BY THE CURRENT PROVIDER OR FINANCIAL ADVISER Note: for multiple transfers, please copy this page and provide the information below for each scheme. What type of scheme or policy is providing the Purchase Amount or the Transfer Payment? Please tick one of the boxes. Stakeholder Pension Scheme Retirement Annuity Contract or Trust Scheme Statutory Scheme Personal Pension Scheme Retirement Benefits Scheme Section 32 or 32A Buy-out Contract Free-standing AVC Scheme (FSAVC) Section 608 Scheme (this is a scheme which was originally approved under S.208 of the Finance Act 1970 and NO contributions have been paid to it since 5 April 1980). Other (other schemes which are not registered pension schemes, for example an overseas scheme - please specify) 1. Full name and address of pension scheme Postcode 2. HMRC pension scheme tax reference number 3. Existing plan number 4. Approximate fund value to be paid to Scottish Widows Does this represent the full value of the existing plan? Yes No Does any part of the transfer payment relate to a pension credit on Yes No divorce/dissolution of a civil partnership? If yes, please tell us any amount which relates to a pension already in payment. No tax free cash can be taken from this amount Does the source of money come from a death in service (see note 1) Yes No 5. Name and address of the Current Provider (This will allow us to contact the current provider direct) Postcode 6. Amount of Lifetime Allowance used up in respect of the Purchase Amount and any tax-free cash. (It is essential this is completed in respect of an Open Market Option.) % 4

Notes to Section E 1) For an OMO any tax-free cash sum will be paid by your current provider. 2) If your tax-free cash is being paid by Scottish Widows and you would like payment by cheque please provide details. E. ABOUT THE BENEFITS REQUIRED 1. Are the proceeds from a Open Market Option (OMO) Transfer Is the maximum tax free cash required? (see note 1) Yes No If no, what percentage or value is to be taken? Details of Bank/Building Society tax-free cash and regular income payments to be paid to Name of Bank/ Building Society Name of account holder(s) Bank/Building Society account number Sort Code Building Society Roll Number OR tax-free cash ONLY by cheque made payable to (see note 2) F. ADVISER CHARGE INFORMATION (TO BE COMPLETED BY THE ANNUITANT) It is a financial services requirement that we provide data as to whether advice was given on the set up of this policy. Was financial advice given? Yes No If you have answered yes complete the following information. Have you involved an adviser: Yes No Adviser Firm name I want to pay an Adviser Charge from the pension fund I don t want to pay an Adviser Charge from the pension fund Please specify amount of Adviser Charge if payable from pension fund: (This should be the amount shown on your quote) the amount of adviser charge a percentage of the pension fund after any tax free cash sum % This is the Adviser Charge you have agreed with your financial adviser. It will be deducted from the pension fund or the balance of the pension fund less the tax free lump sum (for transfers) before buying your annuity. If you have agreed the adviser charge should be paid as a percentage of your pension fund, you should be aware that if you agree to a percentage and your pension fund differs from what has been quoted, then the amount of adviser charge will change from what was shown in your quote. Your financial adviser should make you aware of any changes to the amount of adviser charge paid and any impact on your income. 5

G. MARKETING PREFERENCES Our policy on Data Privacy is included in the additional sheet Important notes for applications. We would like to keep you up to date on products and offers that may be of interest to you. Please select how you would like to hear from us below. These choices won t affect any necessary information we need to send you such as statements and, don t worry, you can change your mind and update your preferences at any time. SCOTTISH WIDOWS WEBSITES You may see relevant messages when you log in to our online services. If you choose no, you may still see messages, but they will not be tailored to you. Yes No EMAIL Yes No POST Yes No DEVICE NOTIFICATIONS As we develop mobile applications you ll receive relevant notifications to your mobile device Yes No TEXT MESSAGES Yes No PHONE Yes No By saying yes, you are giving consent for Scottish Widows to use your personal information to send you relevant offers and information about our products. Scottish Widows includes the following legal entities: Scottish Widows Ltd, Scottish Widows Unit Trust Managers Limited, Scottish Widows Administration Services Limited and HBOS Investment Fund Managers Limited. Occasionally we will send you selected offers from other companies within Lloyds Banking Group that may be relevant to you. H. DECLARATION FOR OPEN MARKET PLANS (OMO) ONLY DECLARATION BY ANNUITANT TO SCOTTISH WIDOWS 1. I declare that to the best of my knowledge and belief, all the information given in this application form, together with the answers I have given whether in my own handwriting or not, are true and complete. 2. I agree any payment of income should be made to my (the annuitant s) bank or building society and the receipt of the income by bank or building society shall be binding on me (the annuitant). 3. I have received the Important Notes for Applications document. For your own benefit and protection, please read each of the statements before signing this application. Scottish Widows will rely on them when administering your contract. If you do not understand any point, please let us know. 4. I agree to Scottish Widows, should it deem necessary, obtaining details from other pension providers of any other retirement benefits to which I/we am/are entitled. 5. I agree to notify Scottish Widows if my/our circumstances change between the date of completing this application and the date the annuity is set up. 6. I confirm that any Adviser Charge deducted from the pension fund, as detailed in Section F of this application is the charge I have agreed with the adviser for providing advice for this annuity. 7. I confirm that any Adviser Charge is for advice and services provided wholly in respect of this annuity by the adviser. I agree to Scottish Widows deducting this Adviser Charge from the pension fund and subsequently paying it to the adviser specified in this application. 6

H. DECLARATION FOR OPEN MARKET PLANS (OMO) ONLY (CONTINUED) DECLARATION BY ANNUITANT TO THE CURRENT PROVIDER 1. I would like to take benefits from the plan(s) listed in section D of this application. 2. I authorise you to release all necessary information to Scottish Widows to enable the transfer of funds to Scottish Widows. 3. I authorise and instruct you to transfer the funds from the plan(s) as listed in section D of this application directly to Scottish Widows. 4. I authorise you 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. 5. Please pay me any tax-free cash as instructed and pay the balance of funds to Scottish Widows to provide me with an annuity on the basis set out in the quotation indicated in section E of this application. 6. Until this application is accepted and complete, Scottish Widows responsibility is limited to the return of the total payment(s) to the current provider(s). 7. Where the payment(s) made to Scottish Widows represent(s) all of the funds under the plan(s) listed in Section D of this application, then payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from the plan(s) listed. 8. Where the payment(s) made to Scottish Widows represent(s) part of the funds under the plan(s) listed in section D of this application, then payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from that part of the plan(s) represented by the payment(s). 9. I confirm that any Adviser Charge paid on my behalf by Scottish Widows on the initial set up of this annuity: is wholly connected to the purchase of this annuity; and is appropriate to the advice and service my adviser provided me in relation to this annuity purchase. If this is not the case then some or all of the Adviser Charge and any tax-free cash may become liable to a tax charge, which I may be responsible for. 7

H. DECLARATION FOR OPEN MARKET PLANS (OMO) ONLY (CONTINUED) DECLARATION BY ANNUITANT TO SCOTTISH WIDOWS AND THE CURRENT PROVIDER 1. I confirm that: The total value of: the pension income and any lump sums I have already taken (including drawdown income and any income taken before 6 April 2006); any pension funds transferred overseas, and; the benefits I am taking now are below the current standard Lifetime Allowance threshold of 1.03m for the tax year 2018/2019; If I have a pension which was in payment as at 5 April 2006 and I have not already taken benefits from another scheme I will provide the current provider and Scottish Widows with further details immediately; I will notify the current provider and Scottish Widows if I am above the standard Lifetime Allowance threshold; I will advise them if I have a protection in place against the Lifetime Allowance tax charge. I will provide a copy of my protection certificate if asked to do so. Understanding the Lifetime Allowance rules is important because if you provide incorrect or incomplete information you may become liable to a Lifetime Allowance tax charge. If you are unsure how to calculate the value of your benefits, please refer to your financial adviser or the current provider(s). 2. I will be solely responsible for any additional tax charges or any penalties which arise if the information provided in this application is incorrect or if I have failed to comply with any aspect of this application. 3. In addition, I promise to accept responsibility in respect of any claims, losses and expenses that Scottish Widows 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. 4. Where I have chosen to take tax-free cash, it is not my intention to make, either directly, indirectly or by someone making contributions on my behalf, a significant* increase in my total expected contributions to registered pension schemes. *A significant increase is where: the total tax-free cash you receive in the 12 month period ending on the day the tax-free cash from this plan is paid, exceeds 7500, and more than 30% of those tax-free cash sums is used to make contributions (either directly, indirectly or by someone making contributions on your behalf, such as your employer) to one or more registered pension schemes over and above the expected level of contributions. This includes any contributions you may have made in anticipation of receiving the tax-free cash. Signature of Annuitant Date (DD MM YYYY) A copy of the completed application is available on request. The policy schedule and policy provisions will be issued when the Annuity is set up. 8

H. DECLARATION FOR OPEN MARKET PLANS (OMO) ONLY (CONTINUED) DECLARATION BY CURRENT PROVIDER I/we, the Trustees/Scheme Administrator* of the registered pension scheme shown in section D, request Scottish Widows to issue an Annuity policy in accordance with particulars given. I/we declare that the statements made are true to the best of our knowledge and belief. I/we authorise payment of the Annuity direct to the annuitant. I/we confirm the purchase price does not include amounts in respect of Guaranteed Minimum Pension or Section 9(2B) rights. I/we agree that the application and the declaration by the annuitant will form the basis of the contract with Scottish Widows. *Delete as appropriate Signature Date (DD MM YYYY) Signature Date (DD MM YYYY) For and on behalf of the Trustees/Administrators (delete as appropriate) 9

I. DECLARATION FOR ALL TRANSFERS TO OUR SCOTTISH WIDOWS APPROPRIATE PERSONAL PENSION PLAN DECLARATION BY ANNUITANT TO SCOTTISH WIDOWS To enable your transfer payment to be paid to Scottish Widows, you must either be or become a member of the Scottish Widows Appropriate Personal Pension Scheme. Scottish Widows is the Administrator of the Scheme and is responsible for running it in accordance with the Scheme Rules. I am or I apply to become a member of the Scheme and: 1. I understand that this application forms part of my contract with Scottish Widows, along with the Rules of the Scheme, the policy provisions, the policy schedule and any document amending the policy schedule. Copies of these are available from Scottish Widows. 2. I agree to the payment of the transfer payment shown to Scottish Widows to provide benefits for me. 3. I understand that on acceptance of the transfer value(s) by Scottish Widows, the current provider will cease to have any liability to me in respect of the transferred benefits, and that neither I nor my dependants, or other beneficiaries, will have further claim on the current provider in respect of the said benefits. 4. I agree to notify Scottish Widows if my circumstances change from the date of completing this application and the date the annuity is set up. 5. I consent to Scottish Widows seeking further information from other pension providers, trustees, or scheme administrators, for any other pension arrangements under which I have benefits. I authorise the provision of any information requested. 6. I declare that to the best of my knowledge and belief, all the information given in this application form, whether in my own handwriting or not, are true and complete. 7. I agree any payment of income should be made to my (the annuitant) bank or building society and the receipt of the income by bank or building society shall be binding on me (the annuitant). 8. I have received the Important Notes for Applications document. For your own benefit and protection, please read each of the statements before signing this application. Scottish Widows will rely on them when administering your contract. If you do not understand any point, please let us know. 9. If I am transferring benefits currently held as GMP or section 9(2B) rights in the transferring scheme, I confirm that I have acknowledged in writing to the transferring scheme that: I have received a statement from Scottish Widows showing the benefits to be awarded in respect of the transfer payment, I accept that the benefits to be provided by Scottish Widows may be in a different form and of a different amount to those which would have been payable by the transferring scheme, and I accept that there is no statutory requirement on Scottish Widows to provider for survivor s benefits out of the transfer payment. I also acknowledge that Scottish Widows is not accepting liability to provide benefits in the form of GMP or section 9(2B) rights. 10. I confirm that any Adviser Charge deducted from the pension fund, as detailed in Section F of this application is the charge I have agreed with the adviser for providing advice for this annuity. 11. I confirm that any Adviser Charge is for advice and services provided wholly in respect of this annuity by the adviser. I agree to Scottish Widows deducting this Adviser Charge from the pension fund and subsequently paying it to the adviser specified in this application. 10

I. DECLARATION FOR ALL TRANSFERS TO OUR SCOTTISH WIDOWS APPROPRIATE PERSONAL PENSION PLAN (CONTINUED) DECLARATION BY ANNUITANT TO CURRENT PROVIDER 1. I would like to take benefits from the plan(s) listed in Section D of this application. 2. I authorise you to release all necessary information to Scottish Widows to enable the transfer of funds to Scottish Widows. 3. I authorise and instruct you to transfer the funds from the plan(s) as listed in Section D of this application directly to Scottish Widows. 4. I authorise you 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. 5. Please transfer the fund(s) listed in Section D of this application to Scottish Widows. Where you have asked me to give you the original policy document(s) in return for the transfer of funds and I am unable to do so, I promise that I will be responsible for any losses and/or expenses which are the result, and which a reasonable person would consider to be the probable result, of any untrue, misleading or inaccurate information deliberately or carelessly given by me, or on my behalf, either in this form or with respect to benefits from the plan. 6. Until this application is accepted and complete, Scottish Widows responsibility is limited to the return of the total payment(s) to the current provider(s). 7. Where the payment(s) made to Scottish Widows represent(s) all of the funds under the plan(s) listed in Section D of this application, then payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from the plan(s) listed. 8. Where the payment(s) made to Scottish Widows represent(s) part of the funds under the plan(s) listed in Section D of this application, payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from that part of the plan(s) represented by the payment(s). DECLARATION BY ANNUITANT TO SCOTTISH WIDOWS AND THE CURRENT PROVIDER 1. I will be solely responsible for any additional tax charges or any penalties which arise if the information provided in this application is incorrect or if I have failed to comply with any aspect of this application. 2. In addition, I promise to accept responsibility in respect of any claims, losses and expenses that Scottish Widows 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. Signature of Annuitant Date (DD MM YYYY) A copy of the completed application is available on request. The policy schedule and policy provisions will be issued when the Annuity is set up. 11

J. LIFETIME ALLOWANCE (FOR TRANSFERS ONLY) What is the Lifetime Allowance? A Lifetime Allowance (also referred to as standard Lifetime Allowance), set by the Government, will apply to the total value of pension benefits you can receive from all your pension plans. The Lifetime Allowance for the 2018/2019 tax year is 1.03m. The State Pension does not count against the Lifetime Allowance. What happens if I exceed this limit? A Lifetime Allowance tax charge must normally be deducted from any pension benefits that exceed the Lifetime Allowance. This charge can either be applied at a rate of 55% if the excess is taken as a lump sum or a rate of 25% if the excess benefits are taken as income. Any benefits taken as income will be taxed at your marginal rate of income tax. What about Protection from the Lifetime Allowance tax charge? It is possible to apply for various forms of protection from the Lifetime Allowance charge. If your application for one or more forms of protection has been successful you should receive a certificate from HM Revenue & Customs (HMRC). For further information on whether you have or should apply for protection please speak to your financial adviser. If transitional protection applies, please provide copies of the relevant certificate(s) issued by HMRC. If you have Primary Protection, we also require confirmation of your remaining Tax Free Cash entitlement. Please complete the relevant sections and sign the declaration in section D. A. Unused Lifetime Allowance Please tick this box if you have sufficient unused Lifetime Allowance to enable the value of the pension benefits to be provided from this plan to be paid without deduction of a Lifetime Allowance tax charge. B. Pensions in payment as at 5 April 2006 Please tick this box if you have no pensions in payment which began before 6 April 2006 OR Confirm the total gross annual amount(s) of pension benefits currently payable from pensions taken before 6 April 2006, or if this pension is in the form of income drawdown, the current maximum yearly income you could take (calculated at the last review date). C. Lifetime Allowance used up Please tick this box if you have not taken any other pension benefits since 6 April 2006 OR Confirm the total percentage of your Lifetime Allowance used up by taking pension benefits on or after 6 April 2006. % D. Declaration I confirm that, to the best of my knowledge, the information provided above, whether in my own handwriting or not, is correct. I understand that any delay in providing the required information and documentation will delay settlement of the pension benefits I have selected, and could result in a Lifetime Allowance tax charge being applied when benefits are taken. Your name (the Annuitant) Your signature Date (DD/MM/YYYY) WARNING A penalty or other fine may be imposed by HMRC if false or misleading information is provided on this form. 12

Scottish Widows Limited. Registered in England and Wales No. 3196171. Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number 181655. 54450 05/18