Buy-out Bond Matrix Funds Application Form

Buy-out Bond Matrix Funds Application Form Please complete in BLOCK CAPITALS. Plan Type (as per the illustration) Intermediary Name R Financial Advisor Name Intermediary Number The heading of each A Personal Details (Member) Mr Mrs Ms Forename section shows who is Surname required to complete the section (the member, his/her spouse or the Address for Correspondence trustees). Under the Criminal Justice Act, 2010, Zurich Life may require clients to provide Evidence of Identity and Proof of Address and other supporting documentation. of Birth Civil Status Email Address Telephone Number (work) Married Single Widow(er) Separated Divorced (home) Sex M F Civil Partner Former Civil Partner (mobile) Nationality Country of Residence Occupation Please describe fully and if your occupation is 'Company Director' please detail the nature of the business. PPS. of Joining Service of Leaving Service of Joining Scheme of Leaving Scheme Special Instructions (i) Have you ever effected an approved Retirement Annuity Contract (i.e. Personal Pension/ Self-employed Pension Policies) in respect of a previous non-pensionable employment or while self-employed? (ii) Are you entitled to benefits from other Retirement Benefit Schemes? (iii) Are you a Proprietary (5) Director? please see note 1 (iv) Are you a 20 Director? please see note 2 te 1: A proprietary (5) director means a director/employee who, either alone or together with his or her spouse and minor children is or was, at any time within 3 years of the date of (a) the specified normal retirement date, (b) an earlier retirement date, (c) leaving service, or (d) in the case of a pension or part of a pension payable in accordance with a pension adjustment order, the relevant date in relation to that order, the beneficial owner of shares which, when added to any shares held by the trustees of any settlement to which the director or his or her spouse had transferred assets, carry more than 5 per cent of the voting rights in the company providing the benefits or in a company which controls that company. te 2: Appendix I of the Revenue Pensions Manual defines a 20 director as someone who directly or indirectly at any time in the last three years owned or controlled more than 20 of the voting rights in the employer company, or in the parent company of the employer company. 1 Continued overleaf

A Personal Details (Member) (continued) If the answer to any of the questions (i) to (iv) is YES, please give details below (continue on a separate sheet, if required). Please include details of all retained benefits, including immediate and deferred pensions for you and your spouse/civil partner and dependants, and lump sums and gratuities payable on death, retirement and leaving service. Please also advise if any of these benefits are subject to a Pension Adjustment Order. Annual Salary/Earnings at of Leaving Service The following must be completed for 20 Directors or if the Scheme Rules require. If you are an Employee: Additional Fluctuating Earnings if any, for the three years immediately prior to leaving service. If you are a 20 Director : Total Earnings for the three years immediately prior to leaving service. B Personal Details (Spouse) Mr Mrs Ms Forename Surname Maiden Name (if applicable) of Birth Sex M F If you choose the PensionSTAR (ARF) investment strategy, you should note that it is currently only possible to invest in an Approved Retirement Fund if you were a proprietary (5) director of the company from whose Pension Scheme a transfer payment was made into your Buy-out Bond or if the transfer payment related to Additional Voluntary Contributions. If your Buy-out Bond cannot be invested in an ARF, this investment strategy may not be suitable for you. C Investment Options (Member) Please select either 1 or 2 below. Units are bought at the ruling price on a date not later than three working days following receipt of the Single Contribution and the completed application form. 1. PensionSTAR Which PensionSTAR investment strategy do you wish to follow? 2. Matrix Fund Choice PensionSTAR (Annuity) OR PensionSTAR (ARF) Please specify in the table below the Matrix Funds in to which your Single Contribution is to be invested at the start of the policy. Please tick here if you would like AutoInvest to apply to your policy. If you choose AutoInvest, over what period do you want to invest your Single Contribution? 6 Months 12 Months And when do you want AutoInvest to start? w After 1 year After 2 years You must specify in the table below the Matrix Funds into which your policy will be switched gradually, as described overleaf in Information about AutoInvest. Sector Fund Name Single Contribution Active Management Please go to Section D. You can choose a maximum of up to 10 Matrix Funds for your investment. Equity Concentrated Funds 5 5 Global 5 5 Europe 5 5 Asia Pacific 5 5 Americas Geographic Funds Irish Equity *These funds are managed by Threadneedle Investments and are subject to an additional management charge of 0.5 per annum. Global Equity Funds Eurozone Equity Asia Pacific Equity American Select* European Select* International Equity Dividend Growth Global Select* 2 Continued overleaf

** This fund is managed by BlackRock Investments and is subject to an additional management charge of 0.7 per annum. The maximum entry age for the SuperCAPP Fund is aged 60 next birthday provided there are at least five years remaining to rmal Retirement Age. Prior approval is required from Zurich Life if the age next birthday exceeds 60. These funds are managed by BlackRock Investments. C Investment Options (Member) (continued) Sector Fund Name Single Contribution Active Management Managed Funds Active Diversified Funds Unitised With Profits Fund SuperCAPP Fixed Interest/ Bond Funds DEPOSIT FUND Deposit Fund Deposit Plus (Series 2) INDE TRACKER / ECHANGE TRADED FUNDS Geographic Funds Dynamic Performance Balanced Cautiously Managed Secure Active Asset Allocation Dynamic Diversified Growth ** Long Bond Active Fixed Income India Equity Europe ex-uk Index Japan Index UK Index Sector Fund Fund TopTech Name 100 Single Contribution Commodity Funds Property Equity Funds Global Commodities Gold European (Ex-UK) Property Australasia Property Fixed Interest/Bond Fund Inflation-linked Bond Strategy funds Strategy Funds OTHER funds Green Resources Earth Resources Diversified Assets TOTAL 100 For this product you can only switch within the Matrix range of funds. Information about AutoInvest AutoInvest allows you to invest your Single Contribution gradually into your chosen funds over a six or twelve month period. This means that you can spread the timing of your initial investment, and avoid the risk of investing all of your money at a particular time e.g. just before a market downturn. If you select AutoInvest then your Single Contribution is invested initially in the Deposit Plus Fund. You can select when AutoInvest starts either 1 month (now), 12 months (1 year) or 24 months (2 years) after the Start of your policy as shown on your Policy Certificate. On the date AutoInvest starts and each month thereafter, a proportion of your holding in the Deposit Plus Fund will be switched into your chosen Matrix Funds, which you have specified above. In this way, your investment will be gradually switched into your chosen funds. You will be fully invested in your chosen funds six or twelve months after AutoInvest starts. These switches will happen automatically and we will not write to you to inform you when each switch has been processed. When all of the switches have been completed, we will write to you to confirm that AutoInvest has completed for your policy. You can instruct us to cease AutoInvest on your policy at any time. Further automatic fund switches will not take place and any part of your investment still in the Deposit Plus Fund will remain there. If you request another switch outside of AutoInvest then AutoInvest also ceases to apply and further automatic fund switches will not take place. D Web Access to Policy Information (Member) You can look up details of your Buy-out Bond (including a daily updated value) online at the Client Centre on www.zurichlife.ie Do you wish to register for the Client Centre? 3

E Policy Details (Trustees) Employee (ordinary contribution) Transfer Payment* Employee (AVC contribution) Employer Total * Are any benefits included in this Transfer Payment the subject of a Pension Adjustment Order? If YES, please attach a copy of this Pension Adjustment Order. F Details of Scheme (from which the transfer payment originates) (Trustees) Full Name of Scheme (the Scheme) Name of Trustee(s) Name of Employer Address of Employer Is the Scheme registered with the Pensions Board? If YES, please provide Pensions Board Reference Number. P B Is the Scheme Exempt Approved under Chapter 1, Part 30 of the Taxes Consolidation Act, 1997? If YES, please provide Revenue Reference Number. rmal Retirement Age under the Scheme S F G Scheme Restrictions (Trustees) If this application is being used to transfer funds from a Buy-out Bond provided by another Life Office there is no requirement to complete this section. Zurich Life will contact the other provider for details of the originating scheme. If the current provider is unable to provide the full data on the originating scheme Zurich Life will contact you again for this information. Please indicate if the original transferring scheme was: a Defined Benefit (DB) Scheme or a Defined Contribution (DC) Scheme If the original transferring scheme was a DC Scheme when the member left the scheme, had the Trustees amended the rules to allow the A(M)RF options for members leaving after 6th February 2011? Does the scheme impose any restrictions on early leavers, other than normal Revenue Limits? If YES, please specify Has the member waived his/her right to a tax-free lump sum on retirement? If the scheme is a DB Scheme, please specify the following criteria: Guaranteed Period 0 years 5 years 10 years Escalation Rate (Please tick) Spouse's Pension Spouse's Death-In-Retirement Pension If YES, please specify spouse s Death-In-Retirement Pension and ensure that the Spouse s Declaration (Section I) is completed. of Member s Pension OR p.a. Please specify any other special conditions imposed on the member by the scheme: 4

Please sign the box at the bottom of Part A. H Declarations Part A (Member) (i) Data Protection Zurich Life Assurance plc ( Zurich Life ) or its authorised agents, may hold, use, disclose and process any information provided by me ( data ), which shall include information contained in this application (or provided subsequently in discussion or otherwise) and any information arising in relation to my policy and my relationship with them, in order to: process this application, manage and administer my policy; provide data to any of the companies that make up the Zurich Insurance Group (the 'Group') to enable them to do so; and provide the data to my Financial Advisor to enable them to administer my policy; comply with legal and regulatory obligations; overview and analyse my policy regularly for Group reporting; communicate with me (subject to legislation) by post, telephone, email or SMS unless instructed not to by me in writing; disclose the data to any (or any proposed) assignee, disposee or successor or any reinsurer; disclose/transfer the data abroad (subject to legislation) for the above purposes to persons approved of by Zurich Life; and check my personal data against international trade/economic or financial sanctions laws or regulations listings. You have a right of access to and the right to rectify data concerning you held by Zurich Life/the Group. Zurich Life may, in future, want to use your data to tell you about its products and services, those of the Group or of a third party that they have arranged for you. If you do not want your data to be used for these purposes, please tick here. You can ask Zurich Life/the Group at any time to stop using your data in this way, by writing free of charge to Customer Services, Zurich Life Assurance plc, Zurich House, Frascati Road, FREEPOST, Blackrock, Co. Dublin. (ii) Consumer Disclosure I confirm that I have received the relevant Customer Guide and that the Customer Guide has been fully completed by my Financial Advisor. Does this policy replace an existing policy(ies), in whole or in part? If YES, and that policy is a Zurich Life policy(ies), please specify policy number(s): If you are transferring from a Defined Benefit Scheme, it is likely that the benefits under your Buy-out Bond will be significantly different in form. For example, the benefit on retirement may be guaranteed under your employer Scheme while Buy-out Bond benefits depend on investment returns (and are not guaranteed). Warning: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or Financial Advisor. (iii) Policy Declaration I agree that the information given shall be the basis of the contract of insurance, and I declare that the statements in this application are true and complete (including any statements written down at my dictation). I understand that my rights under the Scheme are being given up in exchange for a contract under which the ultimate benefits depend on the future investment returns on the fund(s) in which the Transfer Payment will be invested and cannot be guaranteed. I hereby authorise Zurich Life to seek information and obtain benefit details from the administrator/trustees (and/or relevant insurance office) of any scheme, arrangement or contract of which I am or have been a member, and I authorise the Department of Social Protection or the Revenue Commissioners to advise Zurich Life of my most recent address on their records, at any future time. I hereby authorise the Trustees to transfer to a Buy-out Bond (Matrix Funds) the amount that, in the opinion of the said Trustees, represents the value of my benefits on withdrawal under the Scheme. In consideration of the payment of such Transfer Payment to a Buy-out Bond (Matrix Funds), I hereby release the Trustees of the Scheme from all liability to me in respect of benefits under the Scheme with effect from the date of such transfer. If the policy was sold, signed or completed outside Ireland, insert the name of the country where it was sold, signed or completed. I confirm that I have read and fully understand all parts of the above declaration, (Part A, (i), (ii), and (iii)) and that I will be the beneficial owner of the policy. Member Signature of Member Part B - This part should be completed by your Financial Advisor. I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the applicant has been provided with the information specified in Schedule 1 to those Regulations (the relevant Zurich Life Customer Guide) and that I have advised the client as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction, and of possible financial loss as a result of such replacement. Financial Advisor Signature of Financial Advisor 5

Required only if a spouse's pension is provided by the Scheme. I Spouse's Declaration I understand that my rights under the Scheme are being given up in exchange for a contract under which the ultimate benefits depend on the future investment returns on the fund(s) in which the Transfer Payment will be invested and cannot be guaranteed. I understand that the benefits to be provided are specified in Section G. Spouse Signature of Spouse A copy of this complete application form is available on written request within three months of the date of application. A copy of the policy conditions is also available. It is essential that the person(s) signing on behalf of the Trustee(s) is (are) empowered to do so. J Trustee's Application and Declaration (Trustees) (t required when funds are coming from an existing Buy-out Bond) I declare that the information given in this application is complete and correct and request that a Buy-out Bond (Matrix Funds) be issued in the name of the Member in accordance with the details set out above, subject to the privileges and conditions of the standard form of policy issued by Zurich Life Assurance plc (Zurich Life) for a contract of the kind proposed. I confirm that the transfer payment arises from the proceeds of a retirement benefits scheme that is or is to be exempt approved under Chapter I, Part 30 of the Taxes Consolidation Act, 1997 and the proposed benefits correspond with benefits that could be provided in respect of the Member and his/her spouse under the Rules of the Scheme. I confirm that the Scheme documentation empowers the Trustees to purchase the Buy-out Bond (Matrix Funds) for the Member in lieu of the benefits for, or in respect of, the Member and his/her spouse under the Scheme. I understand that Zurich Life will provide only the benefits under the Buy-out Bond (Matrix Funds) and will accept no further responsibility in relation to the Member and his/her spouse. Trustee Signature of Trustee Trustee Signature of Trustee Print Ref: PP292 0412 Product Ref: QAR QAA QA1 Zurich Life Assurance plc Zurich House, Frascati Road, Blackrock, Co. Dublin, Ireland. Telephone: 01 283 1301 Fax: 01 283 1578 Website: www.zurichlife.ie Zurich Life Assurance plc is regulated by the Central Bank of Ireland. Intended for distribution within the Republic of Ireland. The information contained herein is based on Zurich Life s understanding of current Revenue practice as at April 2012 and may change in the future.