Zurich International Portfolio Bond. Application form for use with a Bare Discounted Gift Trust

Zurich International Portfolio Bond Application form for use with a Bare Discounted Gift Trust

Application checklist Both you and your adviser must complete this application form in the appropriate places and sign the relevant declarations. Please review the sections you need to complete, then tick the Complete circles as you finish each section. Customer section Section 1 Your application Complete the relevant part of this section. Required Complete Section 2 Personal details Complete all of this section. applicants/donors Section 3 Personal details Complete all of this section if you are lives insured applying for the life insurance version. Section 4 Investment details Complete all of this section. Section 5 Death benefit Complete this section if you want to remove standard death benefit (does not apply to the capital redemption version). Section 6 Source of investment Complete all of this section for all applicants/donors. Section 7 Investment instructions Complete all of this section. Section 8 Fund declaration Your adviser will tell you if you need to complete this section. Section 9 Discretionary asset Read and sign this section if you manager nomination wish to nominate a discretionary asset manager to manage the assets in your plan. Section 10 Regular withdrawals Complete all of this section. Section 11 Zurich Portfolio option Complete this section if you nominate to have the plan assets managed within a Zurich Portfolio. Section 12 Plan declaration Read and sign this section. Section 13 Adviser authority Read and sign this section with your adviser if you want your adviser to act on your behalf. This page must be signed by the donor(s) as trustee(s) and all additional trustees after the plan and trust have been issued. Adviser section Section 14 Adviser details Completed by your adviser. Section 15 Confirmation of verification Completed by your adviser. of identity certificate (CVI) Additional requirements Original trust deed Cheque payable to Zurich (where applicable) Completed photocopied pages (where applicable) 2

Important notes Completing this application You should complete this application with your adviser who will be able to explain each section. The application checklist on page 2 shows the sections you must complete, and the sections you may need to complete, depending on your preferences. The Zurich International Portfolio Bond (the plan) is provided by Zurich Life Assurance plc, a member of the Zurich Group. Where we refer to Zurich in this application, we are referring to Zurich Life Assurance plc. Data protection Zurich is committed to ensuring that the way we collect, hold, use and share information about you complies fully with the Irish Data Protection Acts 1988 2003. Before completing this application you should read a copy of our leaflet Your privacy is important to us as this explains how your data will be used. If you don t have a copy of our leaflet or would like more information please ask your adviser. 1 Your application Always complete this section. Please make sure you complete all relevant sections and return your application form to Zurich Life Assurance plc at Zurich Centre, PO Box 1076, Bishops Cleeve, Cheltenham, Gloucestershire GL50 9NR, UK. This application form should only be used in connection with a Zurich International Portfolio Bond Bare Discounted Gift Trust. You must first have submitted the health questionnaire and received a discount confirmation. You must also complete a Zurich International Portfolio Bond Bare Discounted Gift Trust Deed and submit it with this application. We can't accept additional payments to plans written under a Bare Discounted Gift Trust. Please select the plan type (please tick). Life insurance version Capital redemption version Please enter your discount confirmation unique reference below. If you have been given a payment reference by Zurich for an electronic payment, please enter the number here. 2 Personal details applicants/donors Always complete this section. How many people are applying for the plan (applicants/donors)? How many lives insured are there? First applicant/donor Surname Second applicant/donor Surname Forename(s) Forename(s) Mr Mrs Miss Ms Mr Mrs Miss Ms Dr Other (please give details) Dr Other (please give details) 3

2 Personal details applicants/donors (continued) First applicant/donor (continued) Second applicant/donor (continued) If the applicants are at different addresses, we will send all correspondence to the first applicant. Contact details Current residential address Contact details Current residential address Neither the applicant nor the applicant s spouse or civil partner can be a life insured. Please provide us with at least one contact number. Daytime telephone Mobile telephone Evening telephone Daytime telephone Mobile telephone Evening telephone Email address Email address Applicants must be aged between 18 and 85. We cannot set up a bond for any applicant who is a US national. of birth Sex Male Female Nationality Town/city of birth of birth of birth Sex Male Female Nationality Town/city of birth of birth of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Occupation and income details must be provided for any live settlors/donors. Occupation Income Occupation Income 4

3 Personal details lives insured The maximum number of lives insured is ten. There are no lives insured if you have selected the capital redemption version. Each life insured must be a beneficiary of the trust. Neither the applicant nor the applicant s spouse or civil partner can be a life insured. Do not complete this section if you are taking out the capital redemption version. Life insured Life insured Surname Surname Forename(s) Forename(s) Mr Mrs Miss Ms Dr Mr Mrs Miss Ms Dr Other (please give details) Other (please give details) Contact details Contact details Current residential address Current residential address Please provide us with at least one contact number. At least one of the lives insured must be aged 79 or less. The minimum age for a life insured is three months. Daytime telephone Mobile telephone Evening telephone Email address of birth Sex Male Female Nationality Town/city of birth of birth Daytime telephone Mobile telephone Evening telephone Email address of birth Sex Male Female Nationality Town/city of birth of birth of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) 5

Personal details lives insured (continued) There are no lives insured if you have selected the capital redemption version. If there are more than four lives insured, please complete their details on a photocopy of this page and ensure it is returned with the application. Each life insured must be a beneficiary of the trust. Life insured Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Contact details Current residential address Life insured Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Contact details Current residential address Neither the applicant nor the applicant s spouse or civil partner can be a life insured. Please provide us with at least one contact number. Daytime telephone Mobile telephone Evening telephone Daytime telephone Mobile telephone Evening telephone Email address Email address At least one of the lives insured must be aged 79 or less. The minimum age for a life insured is three months. of birth Sex Male Female Nationality Town/city of birth of birth of birth Sex Male Female Nationality Town/city of birth of birth of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) 6

4 Investment details Please refer to the Minimum initial payment section of the information leaflet for details of the minimum payment. If the trust has a single donor, the payment should come from the donor's own account. If the trust has joint donors, the payment must come from a joint account or two separate payments each for half of the total payment from each donor's bank account. Always complete this section. Please confirm your chosen currency (this will apply to your payment and will also be your base* currency and benefit* currency). sterling $ US dollars euro Please confirm the amount you would like to invest Payment method Please confirm the payment method Cheque (including banker s draft) please make payable to Zurich CHAPS / TT Your bank may charge you a fee for a CHAPS / TT payment BACS BACS will take a minimum of three working days to reach the Zurich account If you are paying by CHAPS / TT or BACS, you will need to contact Zurich on 0370 850 6130 for a payment reference. Please make sure you write this payment reference in the Your application section (section 1). This will ensure we can match up your payment with your application. * To nominate the Zurich Portfolio option, your base and benefit currencies must be sterling. 5 Death benefit Removing standard death benefit will reduce the yearly charge. Complete this section if you are applying for the life insurance version of the plan. Do not complete if you are taking out the capital redemption version or if the youngest life insured is aged 70 or over. Would you like to remove the standard death benefit? Yes No If you do not answer this question, standard death benefit will apply. If you remove the standard death benefit, the plan will continue to provide a lower level of protection. Please refer to the key features document for further details. 7

6 Source of investment This section must be fully completed in all cases by the first applicant/donor The information requested is necessary to comply with the provisions of the current financial services regulations. Where has the investment come from? Please tick the appropriate source, or use other to give details. Income Savings Inheritance Property sale Other (please specify) Bank details (if you are not paying by cheque) of account holder of bank/building society Account number account is based in Account branch name Sort code BIC/SWIFT code IBAN number Roll number Source of investment This section must be fully completed in all cases by the second applicant/donor (where applicable) The information requested is necessary to comply with the provisions of the current financial services regulations. Where has the investment come from? Please tick the appropriate source, or use other to give details. Income Savings Inheritance Property sale Other (please specify) Bank details (if you are not paying by cheque) of account holder of bank/building society Account number account is based in Account branch name Sort code BIC/SWIFT code IBAN number Roll number 8

7 Investment instructions Always complete this section. Do you want to nominate a discretionary asset manager? No Yes (If yes please go to section 9) Do you want your plan assets managed within a Zurich Portfolio? No Yes (If yes please complete the rest of section 7 and then go to section 11) If you have answered No to the questions above, please indicate in the table below the assets (insured funds, mutual funds and deposit accounts) you want us to invest in on your behalf and also complete section 8. ISIN is not required for some types of asset such as deposit accounts. If an ISIN does not apply, please mark the column as n/a. For deposit account investments please provide the term and interest rate for the account. If any of the information is incomplete or unclear, we will not be able to place the trade. You must put at least 3 into the transaction account. You can find the ISIN for most funds in the Funds charges summary. Each mutual fund you invest in will be subject to a trading charge. Please see the information leaflet for details. We apply minimum investment amounts to each asset. Please see the information leaflet for details. Please complete details of any extra assets on a photocopy of this page and ensure it is returned with the application, if there is not enough space to list your chosen assets. Please give investment amounts to two decimal places. Investments into deposit accounts must be in your chosen base currency. Please see the terms and conditions for details of when we will invest in the assets you have selected. Asset name ISIN Investment (this must be completed for insured funds and mutual funds) Transaction account (you must put at least 3 n/a into the transaction account) Total 100 9

8 Fund declaration This fund declaration must be signed by each applicant if any mutual fund chosen is classed as a qualified fund, experienced investor fund, professional investor fund or specialist fund. Before signing this fund declaration, you should carefully read the terms set out in the prospectus and/or the offering document of the fund. This will tell you if the mutual fund is classed as a qualified fund, experienced investor fund, professional investor fund or specialist fund. Your adviser will be able to explain why these funds do not fall within the category of retail funds in so far as they are not funds designed for general sale to the public. Before signing this fund declaration, your adviser should explain the operation of the mutual fund including all information about risks, charges, penalties and redemption procedures. Before signing this fund declaration, you should seek financial advice regarding the mutual fund you have chosen as investment in the mutual fund is entirely at your own risk. I/We confirm that I/we meet the requirements of the mutual fund prospectus and/or the offering document and instruct Zurich to place instructions to buy the mutual funds set out in this application form. First applicant/donor Second applicant/donor 10

9 Discretionary asset manager nomination You can only nominate a discretionary asset manager that Zurich has an agreement with. A list of discretionary asset managers you can choose from is available from us or your adviser. Complete this discretionary asset manager nomination if you wish to nominate a discretionary asset manager to manage the assets in your plan. Do not complete this section if you are nominating a Zurich Portfolio. The discretionary asset management agreement that Zurich has entered into with the discretionary asset manager is a wide ranging authority which allows the trading of assets and the provision of custody services or the selection of a custodian by the discretionary asset manager. Discretionary asset manager details Company name and address Contact name (if applicable) Custodian name and address (if applicable) Your adviser will tell you what charges apply for the discretionary asset manager you have nominated. Your adviser will tell you which discretionary asset manager is able to offer discretionary management services for your investment objectives and risk profile. Investment objectives and attitude to risk Please confirm your investment objective Please confirm your attitude to risk I/We request that Zurich appoint the discretionary asset manager named above to manage the assets in my/our plan in accordance with my/our investment objectives and attitude to risk. I/We consent to the release of all relevant personal information relating to the plan to the discretionary asset manager. I am/we are aware that the assets managed by the discretionary asset manager will be owned by Zurich. I am/we are aware that Zurich has entered into a discretionary asset management agreement with the discretionary asset manager which prohibits the discretionary asset manager from investing in assets that are not permitted by Zurich. I am/we are aware that Zurich may need to terminate the discretionary asset management agreement it has in place with a discretionary asset manager. In the event of termination, the assets in the unit fund will be sold and the proceeds transferred back to Zurich, only then will Zurich control the assets previously managed by the discretionary asset manager. I/We acknowledge that I/we may request Zurich to terminate the nomination for the discretionary asset manager to manage the assets, which, if accepted by Zurich, will take place only when all the assets in the unit fund have been sold and the proceeds transferred back to Zurich. Before signing this discretionary asset manager nomination, you should be aware that Zurich does not endorse the ability or suitability of any discretionary asset manager that you choose to nominate or any custodian which the discretionary asset manager may select. Before signing this discretionary asset manager nomination, you should be aware that the discretionary asset manager will be responsible for investing in assets in accordance with your investment objectives and attitude to risk. Zurich will not be responsible for the actions or decisions taken by the discretionary asset manager in respect of the assets it chooses to invest in your plan. First applicant/donor Second applicant/donor 11

10 Regular withdrawals Always complete this section unless you are taking withdrawals from a Zurich Portfolio. The maximum regular withdrawal is 5 of your payment each year. Please refer to the information leaflet for details of the minimum regular withdrawal amount and minimum plan value. Please confirm the amount of your regular withdrawal / $ / * each year (*delete as applicable). Regular withdrawals will be taken equally from all policies. Frequency How often do you want to receive a withdrawal? Every month starting one month after commencement Every month starting one year after commencement Once a year starting one year after commencement Bank details of account holder of bank/building society Account number account is based in Account branch name Account branch address Sort code IBAN number BIC/SWIFT code Roll number Withdrawals requested in euro or US dollars require a valid IBAN (international bank account number) and a BIC (bank identifier code) / SWIFT code. Withdrawals must be paid to the applicant s bank account. If the application is from joint applicants, withdrawals must be paid to a joint bank account in the name of the applicants. 12

You must have selected sterling as your base currency and benefit currency if you choose the Zurich Portfolio option. Your adviser will tell you what charges apply to the assets held within a Zurich Portfolio. If there are more than four applicants, please complete their details on a photocopy of this page. Please ensure it is returned with the application. 11 Zurich Portfolio option Only complete this section if you want your plan permitted assets to be managed within a Zurich Portfolio. If you complete this section, you must also complete section 13. A) Zurich Portfolio nomination The agreement that Zurich has entered into with Sterling ISA Managers Limited is a wide ranging authority that allows the trading of assets and the provision of custody services or the selection of a custodian. Sterling ISA Managers Limited details Sterling ISA Managers Limited. Registered in England and Wales under company number 02395416. Registered Office: The Grange, Bishops Cleeve, Cheltenham, GL52 8XX. Sterling ISA Managers Limited will arrange for assets to be registered in the name of Sterling ISA Managers (Nominees) Limited. Declaration I/We request that Zurich appoint Sterling ISA Managers Limited to make the assets in my/our plan available to manage within a Zurich Portfolio. I am/we are aware that, where applicable, Zurich will not sell assets in my/our existing plan until Sterling ISA Managers Limited has confirmed they are able to accept the proceeds of my/our plan into the Zurich Portfolio. I am/we are aware that the assets made available within the Zurich Portfolio will be owned by Zurich. I am/we are aware that Zurich has entered into an agreement with Sterling ISA Managers Limited that prohibits investing in assets that are not permitted by Zurich. I am/we are aware that Zurich may need to terminate the agreement it has in place with Sterling ISA Managers Limited and in the event of termination, Zurich will control the assets previously managed within the Zurich Portfolio. This will take place only when all the assets in the Zurich Portfolio have been sold and the proceeds transferred back to Zurich. I/We acknowledge that I/we may request Zurich to terminate the nomination to have assets managed within a Zurich Portfolio, which, if accepted by Zurich, will take place only when all the assets in the Zurich Portfolio have been sold and the proceeds transferred back to Zurich. I/We acknowledge that Zurich does not endorse the ability or suitability of any adviser or investment adviser that I/we choose to appoint to manage assets held in a Zurich Portfolio. First applicant Second applicant Day Month Year Day Month Year Third applicant Fourth applicant Day Month Year Day Month Year 13

Zurich Portfolio option (continued) B) Zurich Portfolio disinvestment strategy You must confirm how you want Sterling ISA Managers Limited to disinvest plan assets to cover charges. What assets do you want to disinvest first to cover charges? Least volatile mutual fund Most recently purchased mutual fund Proportionately across all mutual funds If you are investing in specific assets that you want to exclude from the disinvestment strategy please confirm details of the assets below. Asset name ISIN Number The maximum regular withdrawal is 7.5 of the plan value each year. C) Regular withdrawals from a Zurich Portfolio Only complete this section if you want to set up or change regular withdrawals from your plan. Instructions given here will replace any existing instructions (additional payments only). Please confirm the amount of your regular withdrawal each year. Regular withdrawals will be taken equally from all policies. You may have to pay tax if your yearly withdrawals are more than 5 of your total initial payment and any additional payment. Frequency How often do you want to receive a withdrawal? Every month Every three months Every six months Every year What date would you like your withdrawals to start? (This must be at least 30 days after we receive your request) What date would you like your withdrawals to end? (optional) It may take up to four working days from the date we receive the money from Sterling ISA Managers Limited for the payment to reach your account. If you don t specify a date, the first withdrawal will be made on the next available withdrawal date after the start date of the plan. This must be at least 30 days after the start date of the plan. For example, if your plan starts on 1 June and you have asked for monthly withdrawals, the first withdrawal will be made on 1 July. If you have asked for withdrawals to be made every six months, the first withdrawal will be made on 1 December and if you have asked for yearly withdrawals, the first withdrawal will be made on the next 1 June. 14

Zurich Portfolio option (continued) Income payment strategy To take regular withdrawals, please confirm what assets you want Sterling ISA Managers Limited to sell to fund the withdrawals you are requesting. I want to take the withdrawals proportionately across all mutual fund assets held in the Zurich Portfolio. I want to take the withdrawals from the assets specified in the table below If you specify for a withdrawal to be taken in whole or in part from a model portfolio, the amount will be taken proportionately from each asset within it and you do not need to specify each individual asset. Asset name ISIN number Withdrawal to be taken from asset () Withdrawal payment details of account holder of bank/building society Account number account is based in Account branch name Account branch address Sort code Roll number A confirmation of verification of identity (see section 17) will need to be completed if the account holder is not an applicant. 15

A copy of this application and the terms and conditions are available on request. Completion of this application does not guarantee acceptance. Please read the data protection leaflet carefully. If you do not understand any of the information set out in the leaflet, please ask for more information before signing the plan declaration. All parties to the plan should be made aware of how their personal information will be held and used. Please ensure they have read this notice and the data protection leaflet. 12 Plan declaration This plan declaration must be signed by each applicant. Before signing this plan declaration, you should be aware that the terms and conditions together with the plan schedule and any summary of plan changes form the basis of the insurance contract and will govern the terms of the plan. Before signing this plan declaration, you should carefully read the key features document so that you understand what you are buying, and then keep it safe for future reference. Before signing this plan declaration, your adviser should explain the operation of the assets including all information about risks, charges, penalties and redemption procedures. I/We ask Zurich to accept this application and issue the plan, which will be divided into a number of separate and initially identical policies, in accordance with the terms and conditions (as amended below). I/We declare that I/we (the applicant(s)) make this application to Zurich on condition that, under the plan that is issued I/we will be entitled to the regular withdrawals specified in this application if I/we (or, where appropriate, the survivor of us) are alive on the date the withdrawal is payable. For the avoidance of doubt, this right shall remain vested in the applicant(s) throughout his lifetime/their lifetimes (and, where appropriate, the lifetime of the survivor of them) regardless of any assignment of the plan that may take place. In the event of an assignment of the plan, Zurich shall be entitled to treat the applicant(s) as irrevocably authorised to deal with the regular withdrawals as agent(s) for the assignee(s) and every assignee shall take the benefit of the plan subject to this provision. The terms and conditions should be amended as follows: In the regular withdrawals section, sections 10.1, 10.4, 10.6 and 10.11 do not apply. This condition overrides any contrary term(s) in the terms and conditions. The issue of an official letter by Zurich will evidence the fact that they have accepted this condition. I/We declare that I am/we are resident or ordinarily resident in the United Kingdom. I/We declare that I am/we are not resident in, or a citizen of, the United States of America or Brazil. I/We declare that to the best of my/our knowledge and belief the information given in this application is true and accurate. Data protection For the purposes of data protection, reference to Zurich Group means Zurich Insurance Group and its subsidiaries. I/We have received a copy of the data protection leaflet Your privacy is important to us. I/We confirm I/we have read the leaflet which explains how Zurich will look after my/our details and I/we consent to: my/our personal data being used in the way described Zurich, its agents and other Zurich Group companies using my/our information for setting up, processing and administering my/our plan Zurich using a reference agency for identity verification and fraud checking purposes. I/We authorise those asked by Zurich to give such information on production of a copy of this consent. Unless you have advised us otherwise, we may share personal data that you provide to companies within the Zurich Group and with other companies that we establish commercial links with so we and they may contact you (by post, email, telephone or other appropriate means) in order to tell you about carefully selected products, services or offers that we/they believe will be of interest to you. By providing us with your details, you consent (and we shall communicate such consent) to companies within the Zurich Group and other companies that we establish commercial links with using your data in this way. If you would prefer us not to do so, please tick here You can ask Zurich at any time to stop using your data in this way by writing to Zurich Life Assurance plc, Zurich Centre, PO Box 1076, Bishops Cleeve, Cheltenham, Gloucestershire GL50 9NR, UK. Continued 16

Plan declaration (continued) I/We have received the consent of the life/lives insured to have their information shared, used and disclosed by Zurich and the Zurich Group in order for this application to be processed by Zurich. First applicant/donor Second applicant/donor 17

13 Adviser authority Plan number This adviser authority is for this plan only. A separate authority is required in respect of each plan. Complete this adviser authority if you want to give authority to your adviser to provide information and/or instructions to Zurich. This section must be completed for every application where the Zurich Portfolio option has been nominated. We hereby authorise the adviser firm detailed below to act on our behalf in relation to the matters indicated below and to provide information and/or instructions to Zurich. We understand that this authority can be withdrawn at any time by written notification to Zurich and that until such notification is received, Zurich is entitled to rely on this authority and act on any information and/or instructions received from the adviser firm as detailed below as if it/they were given directly by us. We understand that Zurich will not be responsible for the actions or decisions taken by the adviser in connection with our plan. By signing this authority, we authorise Zurich to accept instructions from the adviser firm detailed below relating to any of the following, on the condition that any payments are made to the planholders, donor(s) or trust beneficiaries: Change details of the bank account into which regular withdrawals are paid; One-off withdrawal or full cash-in; and Buy and sell assets. Zurich reserve the right to amend this list in which case Zurich will require a new adviser authority from you. This page must be signed by the donor(s) as trustee(s) and all additional trustees after the plan and trust have been issued. First trustee Second trustee Third trustee Fourth trustee If there are more than four trustees, please complete their details on a photocopy of this page and ensure it is returned with the application. The adviser firm: I/We confirm that I/we will act only in accordance with complete instructions from the planholders of the plan, after ensuring the planholders have received the key features document and the terms and conditions and in accordance with the permissions and authority granted by the Financial Services and Markets Act 2000 or any replacement legislation. Adviser firm name Adviser firm address Adviser name Adviser signature (on behalf of the adviser firm) Zurich agency account number 18

To be completed by the adviser 14 Adviser details Adviser name The first adviser details captured will be treated as the lead adviser. Adviser firm Adviser address Financial Services Register Number Email address Mobile telephone number Zurich agency account number Please tick to confirm that the following statement is true: I confirm that all persons involved in transacting this business are authorised or exempt persons as defined in the Financial Services and Markets Act 2000 and are permitted to conduct this type of business. It is an FCA requirement for product providers to report if advice has been given in relation to all plans sold. Please tick if you have not given advice in relation to this application. If you do not tick, you are indicating advice has been given. Can you confirm that there is an insurable interest? Only for the life insurance version. Yes No Lead adviser s signature 19

Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, deputies, and attorneys acting under power of attorney and third parties where you have been required to undertake identification). Please also complete an International Tax Compliance selfcertification for any trustee, third party and attorneys acting under a power of attorney. *Delete as applicable. Beneficial owners must also be identified if different from the applicants. Please tick the standard evidence box if the case is a face to face sale to a UK resident, otherwise the exceeds standards box should be ticked and supporting documentation sent in. Note this certificate must be signed by an officer of the introducer firm, who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records, to which this certificate relates. 15 Confirmation of verification of identity certificate To be completed by an FCA Regulated or EU Regulated Introducer of applicant*/trustee*/third party*/attorney*/ deputy* (in full) of birth Surname Nationality Forename(s) Mr Mrs Miss Ms Dr Previous address if moved in the last three months Other (please give details) Address Telephone number I/We confirm that: a) the information above was obtained by me/us in relation to the customer; b) the evidence I/we have obtained to verify the identity of the customer (tick one only): meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG, or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). c) I/we have reviewed the application and declaration and based on the knowledge gained about the customer, I/we have (tick one only): no reason to believe the International Tax Compliance self-certification needs any follow up action reason to believe the International Tax Compliance self-certification needs follow up action If follow up action is recommended, please explain why: This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; Those who have been subject to Simplified Due Diligence under the Money Laundering Regulations; or Those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant, please give reasons below: We cannot accept photocopies of completed certificates. Adviser name, address and telephone number Zurich agency account number Financial Services Register number Telephone number of person completing this certificate Job title 20

Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, deputies, and attorneys acting under power of attorney and third parties where you have been required to undertake identification). Please also complete an International Tax Compliance selfcertification for any trustee, third party and attorneys acting under a power of attorney. *Delete as applicable. Beneficial owners must also be identified if different from the applicants. Please tick the standard evidence box if the case is a face to face sale to a UK resident, otherwise the exceeds standards box should be ticked and supporting documentation sent in. Confirmation of verification of identity certificate To be completed by an FCA Regulated or EU Regulated Introducer of applicant*/trustee*/third party*/attorney*/ deputy* (in full) of birth Surname Nationality Forename(s) Mr Mrs Miss Ms Dr Previous address if moved in the last three months Other (please give details) Address Telephone number I/We confirm that: a) the information above was obtained by me/us in relation to the customer; b) the evidence I/we have obtained to verify the identity of the customer (tick one only): meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG, or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). c) I/we have reviewed the application and declaration and based on the knowledge gained about the customer, I/we have (tick one only): no reason to believe the International Tax Compliance self-certification needs any follow up action reason to believe the International Tax Compliance self-certification needs follow up action If follow up action is recommended, please explain why: Note this certificate must be signed by an officer of the introducer firm, who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records, to which this certificate relates. This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; Those who have been subject to Simplified Due Diligence under the Money Laundering Regulations; or Those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant, please give reasons below: We cannot accept photocopies of completed certificates. Adviser name, address and telephone number Zurich agency account number Financial Services Register number Telephone number of person completing this certificate Job title 21

Please let us know if you would like a copy of this in large print or braille, or on audiotape or CD. NP127812052 (03/15) RRD The Zurich International Portfolio Bond is provided by Zurich Life Assurance plc. Zurich Life Assurance plc is authorised and regulated by the Central Bank of Ireland and subject to limited regulation by the Financial Conduct Authority for the conduct of insurance business in the UK. Registered office: Zurich House, Frascati Road, Blackrock, Co Dublin, Ireland. Registered in Ireland under company number 58098. Telephone number 0370 850 6130. We may record or monitor calls to improve our service.