With Profits Pension Annuity

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1 With Profits Pension Annuity If you would like help completing your application, please talk to your Independent Financial Adviser. Application form For details about the Liverpool Victoria With Profits Pension Annuity, please see the Key features document and Plan guide. Please write clearly, in block capitals, using black ink. Tick the appropriate boxes, where applicable. Once we receive the fully completed application form and the cancellation period for the chosen Personal Illustration has expired, we will contact your existing arrangement(s) and arrange for the funds to be sent to us, to enable your benefits to be set up. You can use this application form to apply for a With Profits Pension Annuity for either:- a transfer of benefits being made into the Liverpool Victoria (1996) Personal Pension Scheme. or Where multiple transfers of benefits are being made, you can use this form to apply for all such transfers (using sheets additional to the form where there are more than four arrangements involved). Your With Profits Pension Annuity will only be set up once all the funds being transferred have been received by us. exercising an open market option (OMO) under your existing pension arrangement. Where you are exercising the open market option relating to a number of pension arrangements it is necessary for a separate application form to be completed for each arrangement. Each arrangement will be set up as a separate With Profits Pension Annuity when the funds are received, although we will combine the payments if you choose to have the annuities paid on the same day of the month. A copy of this Application form, and the Policy Conditions, are available on request. Checklist To assist you in completing this form we have detailed below the sections you need to complete, depending upon the type of arrangement which the funds are coming from and whether this represents the exercise of an OMO, or a transfer of benefits into Liverpool Victoria s personal pension scheme to provide an immediate annuity. Please ensure that the appropriate sections of the form are fully completed to avoid delay in setting up the benefits. Sections Type of arrangement A B C D E F G H I Personal Pension Scheme - OMO Occupational Pension Scheme OMO* Free Standing Additional Voluntary Contribution (FSAVC) - OMO Buy-out Policy - OMO Pension Transfer to immediate annuity *This section should be used where the omo is in respect of an Additional Voluntary Contribution from the main scheme.

2 Section A - Annuitant s details Mr Mrs Miss Ms Other Forenames in full Surname Address Telephone number (for queries) Day Evening Male Female Date of birth D M Y NI number letters numbers numbers numbers letter Section B - With Profits Pension Annuity details B1 Your Personal Illustration Please enclose a copy of the Personal Illustration you have chosen as the basis of this annuity application. If you cannot do this, please give the details requested below. Illustration ref no Illustration date B2 Your Annuity Start Date On what date do you ideally want your Annuity contract to start? D M Y B3 of tax free cash you want to take (if allowed): None Maximum B4 Anticipated bonus rate (Please tick your chosen rate) 0% 0.5% 1% 1.5% 2% 2.5% 3% 3.5% 4% 4.5%

3 Section H - Declaration To: Liverpool Victoria Friendly Society Limited I apply to purchase a With Profits Pension Annuity and declare and/or agree that: a. I have read the Key Features of the With Profits Pension Annuity. b. I will be bound by the With Profits Pension Annuity Policy Conditions. c. I understand that you will not process this application until after the 14 day cancellation period has ended. d. My annuity cannot start until this application has been accepted by you and all the purchase monies have been paid in full. e. No benefits have been paid to me from the existing arrangement(s), other than tax free cash, where applicable. f. The annuity cannot be surrendered, altered, transferred or assigned except as allowed by statute or the Rules of the scheme shown in this application. g. To the best of my knowledge and belief the information given in this application is true and complete and I will advise you promptly in writing of any change which affects this information. h. I agree that this application shall form the basis of the contract between us. i. Where this application relates to a transfer of benefits into the Liverpool Victoria personal pension scheme I apply to become a member of, and agree to be bound by the Rules of, the Liverpool Victoria (1996) Personal Pension Scheme. j. I understand that where the purchase price relates to occupation pension scheme related benefits, it may be necessary to restrict any increases generated by the policy so that the revised level of pension does not exceed the maximum permitted by the Inland Revenue. k. You may contact the existing arrangement(s) detailed in this application to be contacted and arrange for the fund(s) to be paid to Liverpool Victoria in order that the benefits may be set up. l. I agree to supply you with any additional information you may require for Inland Revenue or administration purposes. m. You may ask other pension scheme providers for information about any pension schemes under which I have benefits, and I authorise the giving of this information. n. You may use information held about me and/or supply this information to other organisations within your Group to keep my records up to date and/or for research purposes Under Data Protection legislation you have the right of access to your personal records held by us. Copies of your completed application and the Policy Conditions are available on request. By signing this declaration I am allowing the Society to process my application using the information that I have provided. I agree that the Society holding this information on computer, paper file or other medium for as long as the application is being considered, for as long as the annuity remains in force and for an appropirate period thereafter. Signed Annuitant Date D M Y

4 B5 Your Annuity Payments Please tick (one box only) to show how you want your annuity paid: In advance In arrears In arrears with proportion without proportion Monthly Quarterly Half-yearly Yearly B6 Guaranteed period You can choose to have a guaranteed period for your annuity. Please indicate your choice below (whole years only maximum 10). No guarantee 5 year guarantee Other period Please specify years If the Annuity purchase is as a result of the exercise of an OMO from an occupational pension scheme, Buy-out policy or FSAVC which offers the flexible use of FSAVC benefits, and the chosen Guaranteed period does not exceed 5 years, are the remaining instalments to be commuted for a lump sum if death occurs within the Guaranteed period? Yes No

5 B7 Dependant s annuity You can opt for a financial dependant to receive a percentage of your income after your death. Please tick (one box only) the amount of dependant s income to be provided. (For transfers of benefits into the Liverpool Victoria personal pension scheme to provide an immediate annuity or Personal Pension Scheme OMO the maximum percentage is 100%; for an OMO from an occupational pension scheme, Buy-out policy or FSAVC the maximum percentage is 2/3rds) None 50% 2/ 3rds 75% 100% Or, choose your own percentage % (1% to 99%) Your dependant s details (if any, eg spouse or child) Please give details of the person who is to receive this income. (If they die before you, no dependant s income will be payable on your death). Dependant s relationship to you If not your spouse or child, is the person named below financially dependent on you in whole or part? Yes No Mr Mrs Miss Ms Other Forenames in full Surname Address Male Female Date of birth D M Y NI number letters numbers numbers numbers letter If the Annuity purchase is as a result of the exercise of an OMO from an occupational pension scheme, Buy-out policy or FSAVC which offers the flexible use of FSAVC benefits, and the chosen Guaranteed period is 1 to 5 years, is the dependant s annuity to be on a with or without overlap basis? (With overlap means that the dependant s annuity will commence on the first due date following the death of the annuitant; without overlap means that the dependant s annuity will commence at the end of the chosen Guaranteed period). With overlap Without overlap

6 B8 If you are divorced Has any of your pension and/or tax free cash been earmarked for an ex-spouse? Yes No If Yes you must enclose the original order from the court (if there has been an amendment to this order you must also include this) and provide the following details in respect of your ex-spouse, where known: Mr Mrs Miss Ms Other Forename(s) in full Surname Address Telephone Number (for queries) Day Evening Male Female Date of birth D M Y NI Number letters numbers numbers numbers letter % of total payment representing ex-spouse s interest % Note: You must inform the ex-spouse of the purchase of the annuity within 14 days from the date of purchase. It is then the ex-spouse s responsibility to contact Liverpool Victoria to claim part of this benefit and advise current bank details. B9 Details of the account to which annuity payments are to be paid Annuity payments will be credited directly to the bank, building society or giro account chosen. Please give details below: Who is to receive the payments? Net to the annuitant (Please complete details below) Gross to the trustees (Liverpool Victoria will send you a form) Note: if part of the pension has been earmarked for an ex-spouse, it will be necessary for us to obtain relevant bank details to enable payments to be made. We will supply a form for completion by the ex-spouse direct to them, where appropriate. Name of bank / building society Address Name of account holder(s) Sort code Account number

7 Details of existing arrangement(s) Important Note: Liverpool Victoria is unable to accept any payment which represents a substitution for any form of State Benefits. Section C - Open Market Option from a Personal Pension Scheme Inland Revenue Approval Ref: Name & Address of Scheme Administrator/ Trustee Tax free cash already taken? Yes No Purchase Price Section D - Open Market Option from an Occupational Pension Scheme (Including Additional Voluntary Contribution arrangements, where applicable) Inland Revenue approval type: Approved (or submitted for approval under Chapter I, Part XIV of ICTA 1988) Approved under S608 of ICTA 1988 (known as Old Code ) Inland Revenue Approval Ref: Name & Address of Scheme Administrator/ Trustee Purchase Price Have any of the benefits accrued on or after 6 April 1997? Yes No

8 Payment of tax free cash: Tax free cash already taken? Yes No If tax free cash has not been taken already please provide the following information: Is the annuitant subject to the regime of the Finance (No.2) Act 1987? Yes No Is the annuitant subject to the regime of the Finance Act 1989? Yes No If either of the above two questions has been answered Yes please give the following: Number of years and completed months pensionable service years months Final Pensionable Remuneration of tax free cash required? Maximum Maximum Benefits Test Inland Revenue maximum pension available from this and any associated employment i.e. before allowance for tax free cash/dependant s annuity Maximum tax free cash available of pension used for tax free cash/dependant s annuity already Section E - Open Market Option from a Free Standing Additional Voluntary Contribution Scheme Inland Revenue Approval Ref: Name & Address of Scheme Administrator Purchase Price Maximum Benefits Test Inland Revenue maximum pension available from this and any associated employment i.e. before allowance for tax free cash/dependant s annuity Maximum tax free cash available of pension used for tax free cash/dependant s annuity already

9 Section F - Open Market Option from a Buy-out policy Name & Address of Provider Purchase Price Have any of the benefits accrued on or after 6 April 1997? Yes No Payment of tax free cash: Is the annuitant subject to the regime of the Finance (No.2) Act 1987? Yes No Is the annuitant subject to the regime of the Finance Act 1989? Yes No If either of the above two questions has been answered Yes please give the following: Number of years and completed months pensionable service years months Final Pensionable Remuneration of tax free cash required? Maximum Maximum Benefits Test Inland Revenue maximum pension available from this and any associated employment i.e. before allowance for tax free cash/dependant s annuity Maximum tax free cash available of pension used for tax free cash/dependant s annuity already

10 Section G - Transfer(s) into the Liverpool Victoria Personal Pension Scheme If you are transferring more than four schemes please give additional details on separate sheets of paper. Please sign, date and attach any sheets additional to this form as they will be part of your application for this Annuity. Arranging the transfer: When we receive this completed form, we will write to the trustees/administrator of your scheme(s) to arrange the transfer. By signing the declaration at the end of this application you give us your authority to do so. Tax free cash: If your transferring scheme provides tax free cash you can choose to put all or some of it towards your Annuity purchase. If you choose to take cash, and the amount shown below is more than you are entitled to, we will write to you and tell you the maximum allowed. Number of arrangements being transferred (if more than four) Scheme 1 Name and Address of insurer/scheme provider Please give the transfer value from this scheme (including any tax free cash). If you do not know the exact figure please estimate: Scheme 2 Name and Address of insurer/scheme provider Please give the transfer value from this scheme (including any tax free cash). If you do not know the exact figure please estimate:

11 Scheme 3 Name and Address of insurer/scheme provider Please give the transfer value from this scheme (including any tax free cash). If you do not know the exact figure please estimate: Scheme 4 Name and Address of insurer/scheme provider Please give the transfer value from this scheme (including any tax free cash). If you do not know the exact figure please estimate:

12 Scheme Administrators/Trustees/Insurers Statement - Open Market Options a. I/we confirm that the information given in this application by me/us is to the best of my/our knowledge and belief true and complete, and I/we will advise you promptly in writing of any change which affects this information. b. I/we agree that Liverpool Victoria set up a With Profits Pension Annuity on the basis of the information contained in this application. c. I/We understand that the annuity cannot start until this application has been accepted by you and all the purchase monies have been paid in full. Signed for and on behalf of the administrator/trustee/insurer* Signed (* please delete as appropriate) Date Name and position of signatory Section I - Documents we need with this application We cannot start your Annuity until we have received all relevant items from the list below. Please tick to show the items enclosed with this application: Additional pension scheme details Separate sheets showing relevant details are only required if you are transferring money from more than four different pension schemes. Please remember to sign and date each additional sheet supplied Annuitant s Birth Certificate If your name now is different from your birth certificate we will need one or more of the following, depending on why your name has changed: Marriage Certificate Decree(s) absolute Deed poll(s) P45 for the current tax year This is not essential, but if you have one, please forward parts 2 and 3 If a dependant s annuity has been chosen: Dependant s Birth Certificate If the dependant s name now is different from the name on the birth certificate we will also need one or more of the following, depending on why the name has changed: Marriage Certificate Decree(s) absolute Deed poll(s) IFA/WPPA/App/ The With Profits Pension Annuity is issued by Liverpool Victoria Friendly Society Limited. Regulated by the FSA. Member of the ABI. Registered Office: County Gates, Bournemouth BH1 2NF. Client Administration Centre: Liverpool Victoria Friendly Society Limited, PO Box 67, The Ziggurat, 25 Grosvenor Road, St Albans, Herts, AL1 3YL. Telephone Calls may be recorded and monitored for training purposes.

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