Retirement Options Personal Retirement Savings Account (PRSA)

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1 Retirement Options Personal Retirement Savings Account (PRSA) Intermediary Name Financial Advisor Name Intermediary Number By completing and returning this form, you are instructing Zurich Life Assurance plc (Zurich Life) to surrender / mature your Zurich Life PRSA Contract(s) and are confirming the Retirement Options selected. There are 8 Retirement Options from which to choose and these are listed below. Please read this form carefully and seek independent financial advice, if required. Please Note - A PRSA Contract can only be surrendered / matured before age 60, (and after age 50, other than due to ill-health) where the contributions to the PRSA have been made in relation to a PAYE / Schedule E employment. In this situation retirement before age 60 constitutes early retirement and as such proof of early retirement from employment will be required before any early retirement benefits can be paid from your PRSA Contract. Personal Details Title : Mr / Mrs / Ms / Other: Forename: Surname: Date of Birth: Please provide a copy of your original birth certificate, passport or driving licence. PPS Number: Address: Contact phone numbers: Home Work Investment Notice: Please note that on receipt of this Retirement Options claim form the proceeds of your PRSA Contract are disinvested with immediate effect. If there is an unforeseen delay of more than one month in processing your Retirement Options due to outstanding requirements, etc, then your maturity value will be increased in line with the corresponding increase in the Zurich Life Secure Investment Fund over this period.

2 Zurich Life PRSA Contract(s) being matured Please list your Zurich Life PRSA Contract Number (s) in the table below. If you have more than one Zurich Life PRSA Contract but are only taking benefits from one PRSA, then please insert the relevant PRSA Contract number only. Zurich Life PRSA Contract Number Maturity Value Zurich Life PRSA Contract Number Maturity Value Retirement Options The values quoted in your Retirement Options letter may have increased or decreased as a result of fluctuations in the underlying investments. However, you should still insert the values quoted in the relevant boxes below to indicate the Retirement Option(s) you have selected. Note: Where you are not selecting one or more of the Options 1 to 8, please delete / cross-out the Section(s) or insert the words Not Applicable across the relevant Section(s). Option 1 Retirement Lump Sum Payment Option I hereby request Zurich Life to issue me with a Retirement Lump Sum Payment of or % of the maturity value (Maximum Allowable is 25%) Please Note: The total maximum allowable Retirement Lump Sum Payment from all sources is currently 575,000, of which the maximum allowable Tax-Free Retirement Lump Sum Payment is 200,000. Both of these limits include all Retirement Lump Sum Payments taken from all other pension arrangements since 7 th December Please note that Retirement Lump Sum Payments between 200,000 and 575,000 will be taxed at standard rate income tax (currently 20%). If applicable this tax will be deducted by Zurich Life and returned to Revenue along with Revenue Form 790AA. Confirmation of Retirement Lump Sum Payments Did you become entitled, on or after 7 th December 2005, to any Pension Benefits, Retirement Lump Sum Payments or any other pension related benefit? YES / NO Prior to, or on, the date of receiving benefits from this Zurich Life PRSA, do you expect to become entitled to any Pension Benefits, Retirement Lump Sum Payments or any other pension related benefit from another pension arrangement? YES / NO If you have answered Yes to either of the above questions, please provide the following details of your pension arrangements in the Table below. Please include full details of all Retirement Lump Sum Payments received from pension arrangements on or after the 7 th of December This includes Retirement Lump Sum Payments that are currently being taken / processed. Zurich Life will include this information when returning the Revenue Form 790AA (Section 790AA TCA Income Tax deducted from excess lump sum)

3 Details of Pension Benefits and Retirement Lump Sum Payments Please provide full information in the Table below in respect of all current Pension Benefits and Retirement Lump Sum Payments taken since 7th December 2005 (please use a separate sheet if necessary). If none then please write None Name of the scheme or pension arrangement Contact details for the Administrator Policy or reference number Type of pension arrangement e.g. PRSA, Personal Pension (RAC), Superannuation / Company Pension Scheme (Note). Date of entitlement to benefits Maturity Value when benefits were paid out (Note) Retirement Lump Sum Paid Taxable Retirement Lump Sum Paid Tax Free Pension 1 Pension 2 Pension 3 Note - If any of the Superannuation / Company Pension Scheme were Defined Benefit schemes, then please confirm the Annual Pension ( p.a.) that you are currently receiving (or that you expect to receive on retirement). Standard Fund Threshold (SFT) / Personal Fund Threshold (PFT) With effect from 7 th December 2010 the maximum tax relieved pension fund from all pension arrangements was reduced to 2,300,000 (the Standard Fund Threshold - SFT). This limit includes all Pension Benefits and Retirement Lump Sum Payments taken since 7 th December At any stage in the past, did you ever apply to Revenue for a Personal Fund Threshold (PFT) for pension funds in excess of a Standard Fund Threshold? Yes / No If Yes and the amount applied for was accepted by Revenue then please provide a copy of your Personal Fund Threshold (PFT) Certificate. Do you have pension benefits with other Life Offices or in other pension schemes? Yes / No If Yes please provide full information (in the Table above) in respect of all Pension Benefits and Retirement Lump Sum Payments taken since 7 th December 2005.

4 Options for Residual Fund Please confirm below the Retirement Option(s) selected for the remaining fund (after payment of the Retirement Lump Sum) by ticking the required Option(s) selected from Option 2 to Option 8 below. Please also provide any Additional Requirements and complete any required Application Form(s) based on your selected Option(s). Approved Minimum Retirement Fund (AMRF) and Guaranteed Lifetime Income Requirement Although you may have satisfied the previous AMRF requirements (with Zurich Life or any other Life Office / Qualifying Fund Manager QFM), we are required to check that you satisfy the current AMRF and Guaranteed Lifetime Income requirement at every subsequent maturity / retirement / withdrawal from a Vested-PRSA (Option 2) and also prior to exercising the Taxable Cash Payment (Option 5). Eligibility Requirements If you are under age 75 and wish to avail of the above options then Zurich Life require proof of the existence of:- i) An Approved Minimum Retirement Fund (AMRF) with an investment amount equal to the current maximum weekly State Pension Contributory (SPC) amount multiplied by 52 multiplied by 10. This amount currently equates to 119,800 (2011). Please enclose confirmation of this AMRF from the Qualifying Fund Manager (QFM) or Life Office. OR ii) A Guaranteed Lifetime Income equal to the current weekly State Pension Contributory (SPC) amount multiplied by 52 multiplied by 1.5. This amount currently equates to 18,000 p.a. (2011). Please enclose confirmation of this income in the form of a payslip or a letter from the organisation(s) paying this income. Option 2 Leave remainder of fund in a PRSA with Zurich Life (Vested-PRSA) I instruct and authorise Zurich Life to leave the remainder of my PRSA fund (after payment of my Retirement Lump Sum) invested in my existing Zurich Life PRSA (also known as a Vested-PRSA). Please Note: Each time you wish to make a future withdrawal from your Vested- PRSA, then you will be required to demonstrate that you satisfy the AMRF / Guaranteed Lifetime Income requirement (applicable at that time, as shown in the Table above) before payment can be made. If you do not satisfy these requirements at the date of the withdrawal, then you will be required to transfer the required amount to an AMRF or retain this amount in the Vested-PRSA. The required amount is equal to the current maximum weekly State Pension Contributory (SPC) amount multiplied by 52 multiplied by 10 and currently equates to 119,800 (2011).

5 Option 3 Invest in ARF/AMRF with Zurich Life I instruct and authorise Zurich Life to invest / % of my PRSA maturity value in a Zurich Life Approved (Minimum) Retirement Fund A(M)RF as per the instructions given on the enclosed A(M)RF Application Form. I confirm that I have read the relevant Customer Guide, and I have completed the necessary A(M)RF Application Form (together with any requirements) and these are now enclosed. Yes / No Option 4 - Purchase of an Annuity from Zurich Life I instruct and authorise Zurich Life to invest / % of my PRSA maturity value to purchase an Annuity from Zurich Life as per the instructions given on the enclosed Zurich Life Annuity Application Form. I confirm that I have read the relevant Customer Guide, and I have completed the necessary Annuity Application Form (together with any requirements) and these are now enclosed. Yes / No Please Note: The declared annuity rate could change if all claim requirements are not received within 10 days of the annuity quotation date. Zurich Life is required to deduct Income Tax, PRSI & USC from any annuity payment(s) and account to the Revenue for such deductions. Please contact the Revenue Commissioners to arrange a Certificate of Tax Credits and Standard Rate Cut-Off Point for this annuity. If you have contacted Revenue in this respect please tick here ( ). Please quote Zurich Life s registered number H. Unless this certificate is received, tax will be deducted by Zurich Life at the emergency rate of Income Tax. If you have a full medical card then please submit a copy with this form. Option 5 - Taxable Cash Payment I instruct and authorise Zurich Life to issue a once-off Taxable Cash Payment of / % less the relevant tax. I confirm that I satisfy the current AMRF / Guaranteed Lifetime Income Eligibility Requirements as stated in the section above and I attach the required confirmation of same. Yes / No Please Note: Zurich Life is required to deduct Income Tax, PRSI & USC from this payment and account to the Revenue for any such deduction. Please contact the Revenue Commissioners to arrange a Certificate of Tax Credits and Standard Rate Cut-Off Point for this payment. If you have contacted

6 Revenue in this respect please tick here ( ). Please quote Zurich Life s registered number F. Unless this certificate is received, tax will be deducted by Zurich Life at the higher rate of Income Tax. If you have a full Medical Card then please submit a copy with this form. Option 6 - Taxable Cash Sum under the Triviality Rule If you are availing of a Taxable Cash Sum under the Triviality Rule then the residual fund (fund after payment of the various Retirement Lump Sums) must be less than 20,000 from all sources. I instruct and authorise Zurich Life to issue a once-off Taxable Cash Sum payment of / _ % in accordance with the Triviality Rule. I confirm that I am eligible to avail of a Taxable Cash Sum under the Triviality Rule as the remaining pension funds from ALL sources (after the deduction of all Retirement Lump Sum Payments) is 20,000 or less. Yes / No Please Note: Zurich Life is required to deduct Income Tax, PRSI & USC from this payment and account to the Revenue for any such deductions. Please contact the Revenue Commissioners to arrange a Certificate of Tax Credits and Standard Rate Cut-Off Point for this payment. If you have contacted Revenue in this respect please tick here ( ). Please quote Zurich Life s registered number H. Unless this certificate is received, tax will be deducted by Zurich Life at the emergency rate of Income Tax. If you have a full Medical Card then please submit a copy with this form. Option 7 - Open Market Annuity Option I instruct Zurich Life to transfer the total maturity value to purchase an Annuity in my name under the Open Market Annuity Option. Details as follows: Life Office / Payee Name Address / Cheque Destination Contact Name / Phone Number Annuity / Policy Reference Number Option 8 Transfer to an A(M)RF other than with Zurich Life I instruct Zurich Life to transfer or % of the PRSA value for investment in an ARF / AMRF in my name.

7 Details as follows: Life Office or QFM / Payee Name Address / Cheque Destination Contact Name / Phone Number AMRF & ARF / Policy Reference Number Pension Adjustment Order or Notice to Trustees In relation to any of the Zurich Life PRSA Contracts listed in the table above and currently being claimed, please confirm whether:- 1) A Pension Adjustment Order has been issued, or is in the process of being issued in respect of any of the PRSA Contracts? Yes / No 2) A Notice to Trustees has been issued in respect of any the PRSA Contracts? Yes / No If Yes to (1) or (2), then please provide a copy of the Pension Adjustment Order or a copy of the Notice to Trustees. Important Note. If this section has not been completed, then Zurich Life will assume that a Pension Adjustment Order or a Notice to Trustees has NOT been issued on these PRSA Contract(s). Declarations by PRSA Contract Holder i) Data Protection and Revenue Commissioners Declaration Zurich Life or their authorised agents may hold, use, disclose and process any information provided by me, which shall include information contained in this Retirement Options Form (or provided subsequently in discussion or otherwise) and any information arising in relation to the processing and administration of my PRSA benefits to comply with legal and regulatory obligations and related matters and to check my personal data against international trade/economic or financial sanctions laws or regulations listings. I consent to Zurich Life seeking information and benefit details from the administrator, trustees or any other relevant Life Office or Qualifying Fund Manager of any scheme, arrangement or contract of which I am or have been a member, and I authorise the giving of such information and details. I consent to Zurich Life disclosing this data to regulatory authorities, or, as required by law to any persons with whom the Zurich Life has a contract as a service provider, to other insurance companies or to other companies in the Zurich Life Group. I authorise the Department of Social Protection or the Revenue Commissioners to advise Zurich Life or their authorised agents of my most recent address on their records at any future time. ii) PRSA Contract Holders Declaration I declare that the statements in this Retirement Options Form are true and complete (including any statements written down at my dictation), and I agree that this

8 declaration shall be the basis for payment of benefits from my PRSA Contract(s) with Zurich Life. I understand that where my Retirement Lump Sum Payments exceeds 200,000 then Zurich Life will deduct standard rate Income Tax on the excess between 200,000 and 575,000 as detailed in Option 1 Retirement Lump Sum. I understand that where early retirement benefits are being taken from a PRSA between the ages of 50 and 60 (other than due to ill-health) then this is only allowed where I was an employee and have retired from my job. In this situation by signing this Declaration I confirm that I was a Schedule E employee (and not a 20% Director and not self-employed) and have now retired. In this respect I enclose a copy of my P45 and a letter from my employer confirming my date of leaving service / retirement. [Please note: if you are a 20% Director then we will also require confirmation that you have severed all links with this employment and have disposed of your shareholding in the employer (from which you are taking early retirement benefits)]. I confirm that I have read and fully understand all parts of the above Declaration. PRSA Contract Holder Name (Please Print) : Signature: Date: Witness Name (Please Print): Signature: Date: Position or Relationship to Contract Holder:

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