REQUEST TO PAY FEES TO YOUR FINANCIAL ADVISER AND/OR FUND ADVISER FROM YOUR EXISTING Old Mutual International Portfolio Bond or Old Mutual International Ireland European Portfolio Bond This document was last reviewed in November 2013. Please confirm with your financial adviser that this is the most up-to-date document for your product or servicing needs. You should use this form to authorise Old Mutual International Isle of Man Limited (Old Mutual International) or Old Mutual International Ireland dac (Old Mutual International Ireland) to pay fees you have agreed with your financial adviser and/or fund adviser from your Old Mutual International Portfolio Bond Life, Old Mutual International Portfolio Bond Redemption or Old Mutual International Ireland European Portfolio Bond Life. BEFORE COMPLETING AND SUBMITTING THIS FORM YOU SHOULD: Speak to your financial adviser to ensure you are following the most suitable course of action for your circumstances Refer to the policy terms and literature Be fully aware of the possible tax consequences that may apply on taking money from the portfolio bond this is particularly important for UK residents Be fully aware that any fees paid to your financial adviser and/or fund adviser may be sent by telegraphic transfer so a bank charge may apply. To complete this form: use CAPITAL LETTERS only use blue or black ink specify choices as appropriate complete all relevant sections do not use correction fluid; any amendments must be crossed out and initialled by all policyholders. Please return the completed form(s) in original, and any title or other documentation where applicable, to: The Portfolio Bond Claims Department, Old Mutual International Business Services, King Edward Bay House, King Edward Road, Onchan, Isle of Man IM99 1NU, British Isles. If you have any Portfolio Bond questions please contact: Old Mutual International Old Mutual International Ireland E-mail: rskmpbclaims@ominternational.com E-mail: pbclaims@ominternational.com Tel: +44 (0)1624 655302 Tel: +44 (0)1624 655753 Fax: +44 (0)1624 655908 Fax: +44 (0)1624 655908 1 of 6
A DETAILS OF THE POLICY FROM WHICH PAYMENT WILL BE MADE Product Provider (the Company ) (please tick as appropriate.): Old Mutual International Old Mutual International Ireland Policy number (for example IPB 12345678) Type of investor (3) Individual Trustee Corporate DETAILS OF TRUSTEE POLICYHOLDER The trust name is (for example the John Brown Will Trust ) DETAILS OF CORPORATE POLICYHOLDER Corporate name DETAILS OF INDIVIDUAL POLICYHOLDER(S) If there are any further policyholders, please photocopy this page, attach the details with this form and tick here. (3) Title (3) POLICYHOLDER 1 Mr Mrs Miss POLICYHOLDER 2 (IF ANY) Mr Mrs Miss Full forename(s) Surname POLICYHOLDER(S) ADDRESS (TRUSTEE, CORPORATE AND INDIVIDUAL) Residential address (Where you are currently living. We are unable to accept PO Boxes and care of addresses) Registered office address (This information must be provided in full. We are unable to accept PO Boxes and care of addresses) Daytime telephone number including dialling code E-mail address Fax number FINANCIAL ADVISER DETAILS Financial adviser company Financial adviser contact number Financial adviser name Financial adviser e-mail address Who is to be contacted in case of queries (3) Policyholder Financial Adviser THIRD PARTY DETAILS If third party/pledge interest exists, please ensure that we have an up to date signatory list. If this has not already been provided, please also include ID and proof of residency of two directors which must be certified as a true copy of the original document. (s) of Pledgee(s) Addresses of Pledgee(s) 2 of 6
B FEES TO YOUR FINANCIAL ADVISER Ongoing service fee Please note: fees can be paid as a monetary amount or as a % of the value of the assets held in the Portfolio Fund for the Policy each year ongoing service fees are paid quarterly, as a regular withdrawal from the Policy a monetary amount must be a whole amount we will continue to pay the fee until instructed by you to change the amount. This means that if you ask us to pay a % fee and make a top up, the amount paid to your financial adviser may increase or decrease if you make a withdrawal the ongoing service fee will be paid in the Policy Currency. Please enter the ongoing service fee amount or percentage you authorise us to pay to your financial adviser each year monetary amount each year or % of the value of the Portfolio Bond fund each year Ad hoc fee Please note: an ad hoc fee is a monetary amount paid as a partial surrender from the policy the monetary amount must be a whole amount an ad hoc fee is a one off payment Please state the currency in which the ad hoc fee is to be paid (3) $ Please enter the ad hoc fee amount you authorise us to pay your financial adviser You only need to complete the table below when there is no available credit balance in your transaction account held with us and you, your fund adviser or the discretionary asset manager need to provide us with asset dealing instructions in order to cover the ad hoc payment. Investment(s) - (to be sold to cover ad hoc part surrender to pay financial adviser fees) (Please include sedol/isin/omiid) Percentage (Please indicate) C FEES TO YOUR FUND ADVISER If there is more than one fund adviser appointed in respect of the Policy, you will need to complete a form for each fund adviser. Where you have already appointed a fund adviser please enter the name of your fund adviser and details of the fees you have agreed will be deducted from the Policy. This is not an appointment of fund adviser form. Fund adviser details Please enter your fund adviser s company name Fund adviser company name Fee shown below applies (please tick as appropriate): equally to all assets in the Portfolio Fund linked to my Policy (regardless of whether there is one or more custodians appointed (fee must be a %)). applies to assets in the Portfolio Fund linked to my Policy held by the following custodian: Name of custodian: continued 3 of 6
C FEES TO YOUR FUND ADVISER (CONTINUED) Fund adviser fee Please note fees can be paid as a monetary amount or as a % of the value of assets in the Portfolio Fund held by the authorised custodian and/or default custodian for which they are appointed as fund adviser each year fund adviser fees are paid quarterly, as a regular withdrawal from the Policy a monetary amount must be a whole amount where the fund adviser is managing assets held with an authorised custodian, you may request (subject to our agreement) that the authorised custodian pays these fees directly to the fund adviser on our behalf. we will continue to pay the fee until instructed by you to change the amount. This means that if you ask us to pay a % fee and make a top up, the amount paid to your fund adviser may increase or decrease if you make a withdrawal. fees are payable to fund advisers only. If a discretionary asset manager has been appointed then no fees should be requested in this form. the fund adviser fee will be paid in the Policy Currency. Please enter the fund adviser fee amount or percentage you authorise us to pay to your fund adviser each year monetary amount each year or % of the value of the assets in the Portfolio Fund held by the authorised custodian and/or default custodian for which they are appointed as fund adviser each year. Where relevant, would you like the authorised custodian (subject to our agreement) to pay the fund adviser fee to the fund adviser directly on our behalf. Yes No Ad hoc fee Please note: an ad hoc fee is paid as a partial surrender from the policy a monetary amount must be a whole amount an ad hoc fee is a one off payment. Please state the currency in which the ad hoc fee is to be paid (3) $ Please enter the ad hoc fee amount you authorise us to pay your financial adviser You only need to complete the table below when there is no available credit balance in your transaction account and you need to provide us with asset dealing instructions in order to cover the ad hoc payment. Investment(s) - (to be sold to cover ad hoc withdrawals to pay fund adviser fees) (Please include sedol/isin/omiid) Percentage (Please indicate) DEALING ADVICE FEE (Only applicable to assets held with our default custodian) The dealing advice fee is a % of the value of assets on the purchase date of a qualifying transaction. Please refer to the Policy Terms for the list of excluded transactions. The dealing advice fee will be payable to your fund adviser on the next quarterly date following the purchase date of the qualifying transaction. The fee must be inclusive of VAT. Please enter the dealing advice fee percentage you authorise us to pay your fund adviser % of the value of assets on the purchase date of a qualifying transaction. Please note that both regular withdrawals and part surrenders count towards the 5% per annum tax deferred withdrawal allowance under current HM Revenue & Customs chargeable event rules. Please also note that if you, your Fund Adviser or the discretionary asset manager where appointed, do not ensure that there is sufficient credit balance in the transaction account held with us or the transaction account held with the authorised custodian (where we agree to them making payment of fund adviser fees on our behalf) to cover the fee, the fee will not be paid. For further details please refer to the Policy Terms. 4 of 6
DECLARATION AND AUTHORISATION This declaration is made by each Policyholder/trustee/authorised signatory for the company who signs below and, where a trustee, all trustees have agreed jointly to this declaration: 1. I/we confirm that I/we have authority to approve these instructions and that I/we instruct Old Mutual International/Old Mutual International Ireland to deduct the fees detailed in this form from the Policy identified in Section A of this form. 2. I/we confirm that I/we have had the opportunity to read the Policy Terms regarding fees, before signing this form. 3. I/we understand that the fee(s) stated in this form will be met as follows: i. ongoing service fee by a quarterly regular withdrawal from the Policy to my/our financial adviser ii. ad hoc fees as a one off partial surrender from the Policy to my/our financial adviser and/or fund adviser iii. Fund adviser fee - by quarterly regular withdrawal from the Policy to my/our fund adviser and either paid from Old Mutual International/ Old Mutual International Ireland or the authorised custodian on its behalf iv. Dealing advice fee - quarterly regular withdrawal from my Policy to my fund adviser. 4. I/we understand that I/we can amend or cancel an ongoing service fee, fund adviser fee, or dealing advice fee facilitated by (or, where relevant for fund adviser fees, on behalf of) Old Mutual International/Old Mutual International Ireland to my/our financial adviser and/or fund adviser by giving notice to Old Mutual International/Old Mutual International Ireland. 5. I/we agree that payment of the regular withdrawal/partial surrender shall constitute full discharge of the liability of Old Mutual International/ Old Mutual International Ireland. 6. I/we confirm Old Mutual International/Old Mutual International Ireland cannot refund a fee once it has been deducted from my Policy. I/we understand that I/we would need to contact my/our financial adviser and/or fund adviser to discuss a refund and that any such payment would be paid to me by my/our financial adviser and/or fund adviser. 7. I/we confirm that Old Mutual International/Old Mutual International Ireland has brought to my attention the importance of discussing the content of this form with my/our financial adviser and/or fund adviser before signing below. 8. I/we confirm that my/our financial adviser has explained the effect that deducting fees from my Policy will have on the future value of my Policy. In particular that there may be tax implications in agreeing to pay fees from my/our Policy. u Old Mutual International/Old Mutual International Ireland does not offer legal, tax or financial advice and we can accept no responsibility for any action taken or refrained from on the basis of information provided by us. Any information provided is based on our understanding of the current law and practice and is subject to change in the future. Signatory 1 Signatory 2 Signatory 3 Signatory 4 5 of 6
www.oldmutualinternational.com Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Old Mutual International Isle of Man Limited is registered in the Isle of Man under number 24916C. Registered and Head Office: King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0)1624 655 555 Fax: +44 (0)1624 611 715. Licensed by the Isle of Man Financial Services Authority. All promotional material is approved by Old Mutual Wealth Limited. Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Financial Services register number 165359. The rules made under the Financial Services and Markets Act 2000 (as amended) for the protection of retail clients in the UK do not apply. Old Mutual International Isle of Man Limited is a member of the Association of International Life Offices. Old Mutual International is registered in the Isle of Man as a business name of Old Mutual International Isle of Man Limited. Old Mutual International Ireland dac is regulated by the Central Bank of Ireland. Registered No 309649. Administration Centre for correspondence: King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU Tel: +353(0)1 479 3900. Fax: +353(0)1 475 1020 Head Office Address: Hambleden House, 19-26 Lower Pembroke Street, Dublin 2, Ireland. VAT number for Old Mutual International Ireland dac is 6329649S. Registered Office: Arthur Cox Building, Earlsfort Terrace, Dublin 2, Ireland. PDF9099/INT16-0888/November 2016 6 of 6