FutureProof Individual Stakeholder Plan

FutureProof Individual Stakeholder Plan Request to change contributions and/or add a transfer payment Please write in CAPITAL LETTERS, with black ink and where appropriate. Add or change a regular contribution Monthly/Yearly/Applicant/Third party/employer Please complete sections 1, 3.1, 3.2, 4, 5, and where appropriate, section 2, the Employer s contribution record and the direct debit(s). Add one or more single contribution(s) Applicant/Third party/employer Please complete sections 1, 3.1, 3.3, 4, 5, and where appropriate, section 2 and the Employer s contribution record. Add one or more transfer payment(s) Transfers from previous pensions You need only complete sections 1, 3.1, 3.4, 4 and 5. In all cases, your adviser should complete the section below, and section 6 where appropriate. Your Plan number Plan holder s full name Did your adviser give you advice in respect of this application? Advice given Advice not given To be completed by the financial adviser This reference is for financial adviser use, as applicable. For transfers please tick to confirm the relevant illustration is attached and that it matches the quoted reference number. Financial adviser s reference Illustrations attached Regular contribution Single contribution Transfer 1 Transfer 2 Transfer 3 Reference number Reference number Reference number Please note: For transfers we won t be able to service this request unless you submit a copy of the correct pre-sales illustration(s). Financial adviser s details Name of regulated firm (sole trader) Address Contact name 1

To be completed by the financial adviser (continued) Warning: sending personal information by email is not secure. Only include your email address if you agree to Clerical Medical sending you emails. Contact telephone number Financial adviser email address FCA reference number Agency number Please confirm which sales consultant you work with. Sales consultant s full name Unless stated below you, the financial adviser, will be sent all the documents. You will always be sent a copy of the policy certificate. Your client will be sent yearly statements. Original policy certificates Send to applicant Send to financial adviser Filling in this form Please return the completed form, along with your personal illustration(s) to: Clerical Medical, PO Box 28121, 15 Dalkeith Road, Edinburgh EH16 9AS Where financial advisers are overseeing additional single contribution(s) they must ensure that money laundering requirements have been met. Where applicable they must also send us a confirmation of verification of identity for each person paying into the plan see page 14. You may be able to claim further tax relief when the applicant is a higher rate/ additional rate taxpayer. For instance, if a legal guardian is a higher rate/additional rate taxpayer, and the applicant is a minor, HMRC will only allow higher rate tax relief if the minor is also a higher rate/ additional rate taxpayer. Important notes about completing this form You or your financial adviser must ensure all the relevant sections are completed. You must read the key features document and your personal illustration before completing this form. Paying contributions guidance notes How much will you contribute? You should note that we will only accept personal contributions that are eligible for tax relief. It is your responsibility to monitor the amount you pay to all registered pension schemes of which you are a member. Your tax relief depends on your main place of residence as advised by HMRC for the current tax year. If you are a Scottish taxpayer the tax relief you will be entitled to will be at the Scottish Rate of income tax, which may be different from the rest of the UK. Your personal contributions, including those paid by a legal guardian or third party must be paid net of basic rate tax at 20%. HM Revenue & Customs (HMRC) will add basic rate tax relief at 20% to your net contributions. We ll invest the total (gross) contribution in your plan. When completing the form you must enter the gross amount you want to pay. This includes the basic rate tax. 1. To work out the gross amount divide the net contributions by 0.80 2. To work out the net amount multiply the gross amount by 0.80 The above assumes you are a basic rate taxpayer. If you pay more than 20% tax on some of your income, you will need to claim the additional tax relief either by contacting HMRC or via your tax return. If your employer is paying your contribution on your behalf, they ll be deducting the net contribution from your salary, unless it is being paid via salary sacrifice in which case it is paid gross. Employer contributions must be paid gross (before tax has been deducted). If your employer is going to either Pay a contribution for the first time, or Continue contributing, but a different amount, or Pay an increased amount on your behalf (by deducting the payment from your net pay and sending it to us) they ll need to complete the Employer s contribution record on page 13. 2

Filling in this form (continued) How must payments be made? Where regular contributions are being paid by Direct Debit, this will be adjusted to reflect the changes you re now making. Single payments must be made either by cheque or electronic transfer (BACS Account number 53865294, Sort Code 56-00-05). Transfer payments can be made by electronic transfer (BACS) or cheque in pounds sterling ( ). Paying by cheque Cheques should be made payable to Scottish Widows Limited. To help prevent fraud please add your name. For example: Scottish Widows Limited AN Other. If you, the payer(s), or the transferring organisation fails to do this we may have to return the cheque. You should also draw a line through any unused space on the cheque so that any unauthorised person(s) cannot add extra numbers or names. Paying by Direct Debit If you want to start paying regularly by Direct Debit you and/or your employer should complete the form at the back of this request. Arranging a pension transfer We don t accept transfers from non-registered schemes other than certain overseas ones. This plan can take transfer payments representing any Guaranteed Minimum Pension (GMP) or Section 9(2B) Rights, however any previous guarantees they had will no longer apply and they will provide the same type of benefits as the rest of the pension fund. If you ve already taken the tax-free cash you cannot transfer your pension fund to this plan and may need to seek guidance from your financial adviser. If you have enhanced or fixed protection: Any transfer of funds must be a permitted transfer, and Paying contributions to a new pension plan will normally mean you ll lose your protection. If you want to maintain your protection you and your adviser will need to satisfy yourselves that the requirements have been met. If you are transferring from a defined benefit scheme, such as a final salary scheme, once we ve received your completed request we will assume that your cancellation period has already expired. This means you cannot change your mind about making the transfer to this plan. 1. Personal details Please complete this section in all circumstances If we accept your request this form will be the basis of your contract with us. You must be under age 75. Please note: If you are completing this on behalf of a minor (for example a child aged 16 or less, or 18 or less if not in full-time employment) please enter the minor s details. Full name Date of birth (DD MM YYYY) Permanent residential address Daytime telephone number 3

1. Personal details (continued) Previous address (only required if you have lived at the above address for less than three months) If you hold more than one nationality, please list them all. If employed, or self-employed, please state your usual occupation. Nationality Country of residence (if other than UK) Occupation 2. Third party s and/or legal guardian and/or employer s details when contributing for the first time 2.1 Third party or legal guardian I am paying contributions on behalf of the planholder Title (Mr/Mrs/Miss/Ms/Dr/Other) Surname First and middle name(s) Date of birth (DD MM YYYY) Where a sole trader is contributing from their business account they will need to provide us with their trading name and address. This must go in the Permanent residential address box. Permanent residential address Daytime telephone number Mobile telephone number Warning: sending personal information by email is not secure. Only include your email address if you agree to Clerical Medical sending you emails. Email address Previous address (only required if you have lived at the above address for less than three months) If more than one nationality is held, please list them all. If employed, or self-employed, please state your usual occupation. Nationality Country of residence (if other than UK) Occupation 4

2. Third party s and/or legal guardian and/or employer s details when contributing for the first time (continued) 2.2 Employer Name and address of employer Type of business carried out Please also arrange for an Employer s contribution record to be completed (see page 13). 3. Increasing/decreasing contributions 3.1 Maximum contributions The Treasury sets an annual allowance on the amount that can be paid into all your registered pension schemes without incurring a tax charge. Higher earners will have a lower annual allowance limit, called the Tapered Annual Allowance. Your annual allowance may also be limited to the Money Purchase Annual Allowance if you have flexibly accessed a pension with us or any other provider. The Money Purchase Annual Allowance (MPAA) is currently 4,000. The MPAA applies to you if you have flexibly accessed your pensions from us or any other provider and have received any of the payments listed below from 6 April 2015 onwards: a payment from a flexible access drawdown fund (also known as a flexi-access drawdown fund); a payment from a capped drawdown fund which would exceed existing capped drawdown limits; a pension encashment (also known as an uncrystallised funds pension lump sum); a payment under a flexible annuity contract; a pension payment from a money purchase scheme which has fewer than 11 other pensioner members; a stand-alone lump sum from a money purchase arrangement where you were entitled to primary protection with a right to take a lump sum of greater than 375,000. The MPAA applies to all contributions you pay (or that are paid on your behalf e.g. employer contributions and death-in-service premiums) each year to all money purchase pension schemes of which you are a member. If the MPAA applies to you and your contributions exceed it, you will be liable to pay a tax charge based on your highest rate of income tax. The MPAA does not apply if you have taken only income from a capped drawdown plan; tax-free cash (pension commencement lump sums) when using your plan to purchase an annuity or drawdown plan; or small pots taken as a cash lump sum. In these circumstances, the higher annual allowance applies to you. Have you flexibly accessed any pensions with us or any other provider? Yes No If Yes Date of first payment (DD MM YYYY) 5

3. Increasing/decreasing contributions (continued) 3.2 Regular contributions Please complete this section if you, a third party, guardian or employer are going to either be adding or amending monthly or annual contributions. Payment date If you ve previously chosen for the amount you contribute to increase automatically via an increase option, this will apply to the new total contribution from the next renewal date. If you have any increase option or waiver of contributions benefit that applies to current regular contributions it will also apply to the increase in contributions. Please note that if we need you to answer further health questions, we will tell you. For monthly contribution plans the changes will take effect on the same day of the month as the plan renewal date. For annual contribution plans, the changes will take effect from the next renewal date, unless you tell us below. If both you and your employer are paying a contribution, they must be at the same frequency and on the same date in each month. Your request to increase contributions won t be processed until you reach your starting date shown below. This means that the increase in contribution will usually be collected with the following month s contribution. When do you want the amended regular contributions to start (MM YYYY) (if other than the next renewal date) Contribution frequency Annually Monthly If the employer is paying for the first time, or changing the contributions it pays itself, or on your behalf, including contributions made by salary sacrifice, they ll need to complete the Employer s contribution record on page 15, and the financial adviser will need to complete the confirmation of verification of identity for corporate clients which is available on our website at: www.clericalmedical.co.uk Contribution details You can find what minimum additional contribution you can make on our website at: www.clericalmedical.co.uk New total New Amount of Amount of contributions Who will be paying? contribution* increase** decrease (gross) I ll be paying my own contribution A contribution is being paid by a legal guardian or a third party My employer is paying a contribution My contribution is being paid on my behalf by my employer, and from my net pay *Where no contributions have previously been paid. **Excluding automatic increases via the increase option. Addition of increase option Please note: If the increase option is added to regular pension contributions it will also apply to the cost of any waiver of contribution benefit. If you select an increase option it will apply to all regular contributions being made to the plan by you and/or the legal guardian and/or the third party and/or your employer. Do you want the above regular contributions to increase automatically each year? Yes No If Yes, by how much do you want them to increase automatically each year? 5% 10% Retail Prices Index Average Weekly Earnings Index (minimum of 5%) (minimum of 5%) If the first automatic increase is not to be made on the next available renewal, please indicate from which future renewal it is to be made. (YYYY) 6

3. Increasing/decreasing contributions (continued) 3.3 Additional single contributions If the employer is paying for the first time, or changing the contributions it pays itself or on your behalf, they will need to complete the Employer s contribution record on page 15, and the financial adviser will need to complete the confirmation of verification of identity for corporate clients which is available on our website at: www.clericalmedical.co.uk See Arranging a pension transfer in the Paying contributions guidance notes on page 3. When your transfer payment is part of a block transfer, you may, in certain circumstances, retain any pre A-Day entitlement to tax-free cash sum(s) in excess of 25%. Your adviser can give you more details. Contribution details Who will be paying? How much? I ll be paying my own contribution (gross) A contribution is being paid by a legal guardian or a third party (gross) My employer is paying a contribution (gross) My contribution is being paid on my behalf by my employer (gross) 3.4 Transferring benefits into this plan Please note: You ll need to get advice from your current provider(s) about the forms they ll need you to complete. If they need you to complete any forms, you ll be required to return some of these with this request. We cannot process this request without them. Warning. Deciding whether or not to transfer can be complicated. Therefore, before you sign your application, you should satisfy yourself that transferring your benefits is right for you. It is important that you are sure about the suitability of transferring, and that you understand the risks by seeking advice from your financial adviser. Your financial adviser may make a charge for advice. Transfer payment 1 Is this part of a block transfer? Yes No Is any part of this transfer from a Pension Credit? Yes No Amount of transfer payment Guarantee expiry date (DD MM YYYY) Full title of transferring scheme or contract Policy number of transferring scheme Is the transferring scheme or contract registered? Yes No The Pension Scheme Tax Reference (PSTR) that applies to this scheme. The current provider will know this. Pension Scheme Tax Reference Name, address and telephone number of either the administrator of the transferring scheme or the current provider of the contract: Name Address Daytime telephone number 7

3. Increasing/decreasing contributions (continued) When your transfer payment is part of a block transfer, you may, in certain circumstances, retain any pre A-Day entitlement to tax-free cash sum(s) in excess of 25%. Your adviser can give you more details. Transfer payment 2 Is this part of a block transfer? Yes No Is any part of this transfer from a Pension Credit? Yes No Amount of transfer payment Guarantee expiry date (DD MM YYYY) Full title of transferring scheme or contract Policy number of transferring scheme Is the transferring scheme or contract registered? Yes No The Pension Scheme Tax Reference (PSTR) that applies to this scheme. The current provider will know this. Pension Scheme Tax Reference Name, address and telephone number of either the administrator of the transferring scheme or the current provider of the contract: Name Address Daytime telephone number When your transfer payment is part of a block transfer, you may, in certain circumstances, retain any pre A-Day entitlement to tax-free cash sum(s) in excess of 25%. Your adviser can give you more details. Transfer payment 3 Is this part of a block transfer? Yes No Is any part of this transfer from a Pension Credit? Yes No Amount of transfer payment Guarantee expiry date (DD MM YYYY) Full title of transferring scheme or contract Policy number of transferring scheme Is the transferring scheme or contract registered? Yes No The Pension Scheme Tax Reference (PSTR) that applies to this scheme. The current provider will know this. Pension Scheme Tax Reference Name, address and telephone number of either the administrator of the transferring scheme or the current provider of the contract: Name Address Daytime telephone number 8

4. Investment instructions Please complete this section in ALL circumstances. Please indicate your choice of investment funds for new contributions or transfers. If you don t complete the information we ll automatically invest your contributions in your current fund selection. Please choose just ONE of the following two options (A or B), and enter whole percentages only. If you re currently invested in the balanced lifestyle investment programme and you choose to invest in a different fund or funds, the balanced lifestyle investment programme will end. No further automatic switches will take place. Your existing units will remain in the funds they were invested in under the lifestyle investment programme unless you tell us otherwise and by completing a Request for a fund variation form (reference G986). This form may be obtained either from your financial adviser or from our website at: www.clericalmedical.co.uk It is not possible to leave some of your units invested in the balanced lifestyle investment programme. A. Investment funds If you only show your investment choice for one contribution type, then any contributions of another type will be invested on the same basis. You can invest in as many different funds as you wish. To switch any parts of your plan not covered by this form (for example your existing funds to another investment fund), please complete a Fund variation form (reference G986). Investment fund information is available in the funds and prices area of our website at: www.clericalmedical.co.uk Alternatively, please speak with your financial adviser. Each fund has its own aims and risks. Please speak with your financial adviser. We can change the range of funds available. Contribution types Totals in each column must add up to 100%. Investment fund name Please state in whole percentages only. This column is for you to state the fund(s) you want Regular Single to invest in. Please provide the full fund name. contributions contributions Transfer(s) 1. % % % 2. % % % 3. % % % 4. % % % 5. % % % 6. % % % 7. % % % 8. % % % 9. % % % 10. % % % Total 100% 100% 100% OR Ask your financial adviser for details of the balanced lifestyle investment programme (please see notes above). B. The Balanced lifestyle investment programme Please tick here to choose the balanced lifestyle investment programme. 9

5. Declaration This section must be completed in ALL circumstances. I declare that: i) All answers completed by me in this request are correct and complete to the best of my knowledge and belief. ii) I have read (or have had read to me) any answers completed by someone else and confirm that they are correct. Where a transfer is included I consent to: i) Clerical Medical and/or my financial adviser seeking information from the administrator(s) of the following transferring scheme(s) or the insurer(s) of the contract(s), and ii) The administrator(s) or insurer(s) providing such information. The transferring schemes are: Transferring scheme 1 Transferring scheme 2 Transferring scheme 3 Where the provider(s) of the transferring scheme(s) or contract(s) named above requires the completion of a discharge form, please tick one of the following: the signed discharge form(s) has/have been sent to the ceding scheme(s) and a copy/ies is/are enclosed the original discharge form(s) is/are attached Where the provider(s) of the transferring scheme(s) or contract(s) does not require the completion of a discharge form: i) I instruct the named provider(s) to transfer the benefits from the policy(ies) listed in section 3.4 to this plan ii) I discharge the transferring provider(s) from all liabilities under the policy(ies) listed. 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 Clerical Medical showing the benefits to be awarded in respect of the transfer payment I accept that the benefits to be provided by Clerical Medical 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 Clerical Medical to provide for survivor s benefits out of the transfer payment. I also acknowledge that Clerical Medical is not accepting liability to provide benefits in the form of GMP or section 9(2B) rights. Authorisation I hereby authorise Scottish Widows Limited to apply the above stated addition(s) and/or increase(s) in accordance with the terms and conditions of the Scheme and the instructions mentioned above. Data Privacy Notice Who looks after your personal information Your personal information will be held by Scottish Widows Ltd which is part of the Lloyds Banking Group. More information on the Group can be found at www.lloydsbankinggroup.com Our full privacy notice This privacy notice contains key information about how we will use and share your personal information and the rights you have in relation to this. If you want to know more please access our full privacy notice at www.scottishwidows.co.uk/legalprivacy or ask us for a copy. How we use your personal information We will use your personal information: to provide products and services, manage your relationship with us and comply with any laws or regulations we are subject to (for example the laws that prevent financial crime or the regulatory requirements governing the products we offer). 10

5. Declaration (continued) for other purposes including improving our services, exercising our rights in relation to agreements and contracts and identifying products and services that may be of interest. To support us with the above we analyse information we know about you and how you use our products and services, including some automated decision making. You can find out more about how we do this, and in what circumstances you can ask us to stop, in our full privacy notice. Who we share your personal information with Your personal information will be shared within Lloyds Banking Group and other companies that provide services to you or us, so that we and any other companies in our Group can look after your relationship with us. By sharing this information it enables us to better understand our customer s needs, run accounts and policies, and provide products and services efficiently. This processing may include activities which take place outside of the European Economic Area. If this is the case we will ensure appropriate safeguards are in place to protect your personal information. You can find out more about how we share your personal information with credit reference agencies below and can access more information about how else we share your information in our full privacy notice. Where we collect your personal information from We will collect personal information about you from a number of sources including: information given to us on application forms, when you talk to us in branch, over the phone or through the device you use and when new services are requested. from analysis of how you operate our products and services, including the frequency, nature, location, origin and recipients of any payments. from or through other organisations (for example card associations, credit reference agencies, insurance companies, retailers, comparison websites, social media and fraud prevention agencies). in certain circumstances we may also use information about health or criminal convictions but we will only do this where allowed by law or if you give us your consent. You can find out more about where we collect personal information about you from in our full privacy notice. Do you have to give us your personal information We may be required by law, or as a consequence of any contractual relationship we have, to collect certain personal information. Failure to provide this information may prevent or delay us fulfilling these obligations or performing services. What rights you have over your personal information The law gives you a number of rights in relation to your personal information including: the right to access the personal information we have about you. This includes information from application forms, statements, correspondence and call recordings. the right to get us to correct personal information that is wrong or incomplete. in certain circumstances, the right to ask us to stop using or delete your personal information. from 25 May 2018 you will have the right to receive any personal information we have collected from you in an easily re-usable format when it s processed on certain grounds, such as consent or for contractual reasons. You can also ask us to pass this information on to another organisation. You can find out more about these rights and how you can exercise them in our full privacy notice. Other individuals you have financial links with We may also collect personal information about other individuals who you have a financial link with. This may include people who you have joint accounts or policies with such as your partner/spouse, dependents, beneficiaries or people you have commercial links to, for example other directors or officers of your company. We will collect this information to assess any applications, provide the services requested and to carry out credit reference and fraud prevention checks. You can find out more about how we process personal information about individuals with whom you have a financial link in our full privacy notice. How we use credit reference agencies In order to process your application we may supply your personal information to credit reference agencies (CRAs) including how you use our products and services and they will give us information about you, such as about your financial history. We do this to assess credit worthiness and product suitability, check your identity, manage your account, trace and recover debts and prevent criminal activity. 11

5. Declaration (continued) We may also continue to exchange information about you with CRAs on an ongoing basis, including about your settled accounts and any debts not fully repaid on time, information on funds going into the account, the balance on the account and, if you borrow, details of your repayments or whether you repay in full and on time. CRAs will share your information with other organisations, for example other organisations you ask to provide you with products and services. Your data will also be linked to the data of any joint applicants or other financial associates as explained above. You can find out more about the identities of the CRAs, and the ways in which they use and share personal information, in our full privacy notice. How we use fraud prevention agencies The personal information we have collected from you and anyone you have a financial link with may be shared with fraud prevention agencies who will use it to prevent fraud and money laundering and to verify your identity. If fraud is detected, you could be refused certain services, finance or employment. Further details of how your information will be used by us and these fraud prevention agencies, and your data protection rights, can be found in our full privacy notice. How we share personal information about insurance products If you apply to us for insurance, we may pass your details to the relevant insurer and their agents. If a claim is made, any personal information given to us, or to the insurer, may be put onto a register of claims and shared with other insurers to prevent fraudulent claims. Our full privacy notice It is important that you understand how the personal information you give us will be used. Therefore, we strongly advise that you read our full privacy notice, which you can find at www.scottishwidows.co.uk/ legalprivacy or you can ask us for a copy. How you can contact us If you have any questions or require more information about how we use your personal information please contact us using www.scottishwidows.co.uk/secure/forms/contact_us/individual_customers/ policy-enquiries You can also call us on 0345 300 2244. If you feel we have not answered your question Lloyds Banking Group has a Group Data Privacy Officer, who you can contact on 0345 300 2244 and tell us you want to speak to our Data Privacy Officer. Money Laundering Regulations Under current regulations we are required to verify the identity of our customers. In order to meet this requirement and for the prevention and detection of fraud, we will access information from a credit reference agency* to confirm your identity. They will authenticate your name, address and date of birth, which involves checking the details you supply against those held on any databases that the company carrying out the checks on our behalf (or any similar company) has access to. This includes information from the Electoral Register. We will use scoring methods to authenticate your identity. Our search will not be used by lenders or insurers when assessing lending or insurance risks. We may also pass information to financial and other organisations involved in money laundering and fraud prevention to protect ourselves and our customers from theft and fraud. If you give us false or inaccurate information and we suspect fraud, we will record this and share this information with other organisations. If you provide us with information about another person, we will treat this as confirmation that they have appointed you to act for them to consent to the processing of their personal data. This means that you have informed them of our identity and the purpose for which their personal data will be processed, namely to verify their name, address and date of birth. Where Clerical Medical receives notification affecting the legal ownership of the plan, or the appointment of an attorney under a Power of Attorney or other circumstances where there are new parties associated with the contract, the same process as set out above will apply. Please note that if we cannot confirm your name, address and date of birth by using a credit reference agency we may contact you to ask you to supply certain documents to verify this information. If you ask, we will tell you which credit reference agency we have used so you can get a copy of your details from them. *Please note we only use this agency to verify identity to fulfil anti-money laundering regulations and not to check credit worthiness. 12

5. Declaration (continued) Marketing Preferences 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. For your own benefit and protection it is important that you read the key features document and your personal illustration carefully before signing this request form. You should also read the Important notes about completing this form on page 2, and the Data Privacy Notice and Money Laundering Regulations notes above. Clerical Medical will rely on them when administering your contract. If you don t understand any point please ask your financial adviser for further information. By signing the box below I confirm that I have read (or have had read to me) the Important notes about completing this form on page 2 and the Data Privacy Notice and Money Laundering Regulations notes above. Must be signed. Signature of applicant or legal guardian Date (DD MM YYYY) Name in CAPITAL LETTERS 13

6. Confirmation of verification of identity This section must be completed by the financial adviser. Notes on completing the Money Laundering section 1. A copy of the form entitled Confirmation of verification of identity for corporate clients must be completed where an employer (or other corporate body) is paying contributions into the plan for the first time. 2. If required you can find confirmation of verification of identity forms on our website at: www.clericalmedical.co.uk These are: Individual clients include each legal guardian, a trustee (where a firm of trustees is contributing, each individual trustee will need to be verified), an attorney or a sole trader if trading from their home address. Corporate clients include an employer (eg sole trader with a business address, partnerships, limited companies, etc), charity, school or club. A confirmation of verification of identity for corporate clients is available on our website at: www.clericalmedical.co.uk i) Confirmation of verification of identity for individual clients ii) Confirmation of verification of identity for corporate clients 3. You cannot use either of the above confirmations to verify the identity of any customer who falls into one of the following categories: i) Anyone who is exempt from verification because they were an existing client of the introducing firm before identity verification was required ii) Anyone whose identity has not been verified because a permitted exemption applies under the Money Laundering Regulations iii) Anyone whose identity has been verified using the source of funds as evidence. Confirmation of verification of identity of persons contributing to this plan (Not required for transfers) By ticking this box I confirm that I have verified the identity of the applicant named in section 1 (on page 3), and have obtained the required evidence. (If applicable) By ticking this box I confirm that I have verified the identity of the third party named in section 2.1 (on page 4), and have obtained the required evidence. Confirming the employer s identity If they are contributing for the first time, please complete a confirmation of verification of identity form for corporate clients, and submit it with this request. Confirmation I/We confirm that: a) I/We obtained the information about the payee(s) given in this request form. b) The evidence I/we have obtained to verify the customer s identity. Meets the standard evidence set out within the guidance for the UK Financial Sector issued by the JMLSG Must be signed. Signature Date (DD MM YYYY) Full name Position Name of regulated firm (or sole trader) Address Contact s daytime telephone number Agency number 14 FCA reference number

FutureProof Individual Stakeholder Plan Employer s contribution record Where applicable to be completed by the planholder s employer where the employer is either going to contribute for the first time or where existing amounts are being changed. Please return the completed form to: Clerical Medical, PO Box 28121, 15 Dalkeith Road, Edinburgh EH16 9AS Employers must complete this section if they are paying a contribution or if they are paying direct to us an employees personal contribution that is being deducted from their salary. Employee s surname Employee s first and middle name(s) Employee s date of birth (DD MM YYYY) Employee s National Insurance number We re paying a contribution on behalf of an employee (or via salary sacrifice) We re paying an employee s personal contribution direct to Clerical Medical as a deduction from their salary If you ve ticked either of the above statements, you must prepare and maintain a record of the contributions due to be paid direct to an employee s pension arrangements. This is known as a direct payment arrangement. As the provider of your employee s personal pension scheme we ve a duty to report to the Pensions Regulator if contributions under a direct payment arrangement are received late or missed or are lower than the contribution amount. The due date for all contributions is the 19th of the month following the month in which pay day falls or contributions are deducted from pay. Please note: The due date is not the date on which we are expecting you to pay contributions; it s the date by which the law requires you to have paid the contributions. We must also report to the Pensions Regulator if we do not receive a contribution record from you. Record of contributions due Scheme name and address Clerical Medical Investment Group Limited Stakeholder Pension Scheme Clerical Medical, PO Box 28121, 15 Dalkeith Road, Edinburgh, EH16 9AS. Employer s name Address Daytime telephone number

Employer s contribution record (continued) Nature of the business Contact at employer (eg the company s pension administrator or accountant) As shown in section 3 of this form. When are regular contributions to start? (DD MM YYYY) From which month will these be deducted from your account and/or the member s salary? (MM YYYY) Contributions due How much? *Only complete if you, the employer, are paying the employee contributions by deductions from their net salary and are paying net of basic rate tax. This does not include contributions made by salary sacrifice. Employee regular* (gross) Employer regular (including salary sacrifice) (gross) Employee single* (gross) Employer single (including salary sacrifice) (gross) We confirm that: The above information is correct and we will notify you if any of these details change The amounts and frequencies of the contributions (and any automatic increases) shown for contribution by the employer in section 3 of this form are correct and acceptable. Must be signed. Signed for on behalf of the employer Date (DD MM YYYY) Full name in CAPITAL LETTERS Position within the company www.clericalmedical.co.uk Clerical Medical is a trading name of Scottish Widows Limited. Scottish Widows Limited is 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. G1057/0618

Instruction to your bank or building society to pay Direct Debit Please complete the whole of this form and send it to: Originator s Identification Number Clerical Medical, PO Box 28121, 15 Dalkeith Road, Edinburgh, EH16 9AS. 9 5 8 9 4 4 Bank or building society branch full postal address and account details Name(s) of account holder(s) For Clerical Medical official use only. This is not part of the instruction to your bank or building society. Bank or building society account number Branch sort code To: The Manager Bank/Building society Address Instruction to your bank or building society Please pay Scottish Widows Limited Direct Debits from the account detailed on this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that the instruction may remain with Scottish Widows Limited and, if so, details will be passed electronically to my bank/ building society. Signature(s) Clerical Medical reference number Please detach this guarantee and keep it for your future reference. 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 Scottish Widows Limited will notify you ten working days in advance of your account being debited or as otherwise agreed. If you request Scottish Widows Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. www.clericalmedical.co.uk Date (DD MM YYYY) Banks and building societies may not accept Direct Debit instructions for some types of account. If an error is made in the payment of your Direct Debit, by Scottish Widows 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 Scottish Widows 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. Clerical Medical is a trading name of Scottish Widows Limited. Scottish Widows Limited is 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. G1057/0618 G1057/0618

Instruction to your bank or building society to pay Direct Debit Please complete the whole of this form and send it to: Originator s Identification Number Clerical Medical, PO Box 28121, 15 Dalkeith Road, Edinburgh, EH16 9AS. 9 5 8 9 4 4 Bank or building society branch full postal address and account details Name(s) of account holder(s) For Clerical Medical official use only. This is not part of the instruction to your bank or building society. Bank or building society account number Branch sort code To: The Manager Bank/Building society Address Instruction to your bank or building society Please pay Scottish Widows Limited Direct Debits from the account detailed on this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that the instruction may remain with Scottish Widows Limited and, if so, details will be passed electronically to my bank/ building society. Signature(s) Clerical Medical reference number Please detach this guarantee and keep it for your future reference. 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 Scottish Widows Limited will notify you ten working days in advance of your account being debited or as otherwise agreed. If you request Scottish Widows Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. www.clericalmedical.co.uk Date (DD MM YYYY) Banks and building societies may not accept Direct Debit instructions for some types of account. If an error is made in the payment of your Direct Debit, by Scottish Widows 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 Scottish Widows 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. Clerical Medical is a trading name of Scottish Widows Limited. Scottish Widows Limited is 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. G1057/0618 G1057/0618

www.clericalmedical.co.uk Clerical Medical is a trading name of Scottish Widows Limited. Scottish Widows Limited is 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. G1057/0618