Application Form. Before you complete this form. For Intermediary completion only. No ID or age evidence required

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1 No ID or age evidence required PENSION Pension Annuity Annuity Application Form Before you complete this form n n Please read the key features document, as it contains important information about your annuity. Please note that we can t accept any pension funds with an earmarking order (Pension earmarking is one of the options available on divorce or the dissolution of a civil partnership.) For Intermediary completion only Intermediary Financial Services Register number Intermediary address I confirm that any adviser charge (if applicable) is only for pension advice in connection with the purchase of this annuity Phone No Yes Quote Reference A N N When you ve completed this application form please send this back to us, at: Annuities New Business, LV= Retirement Solutions, Keynes House, Tilehouse Street, Hitchin, Herts SG5 2DX.

2 Pension Annuity You should complete this form If you wish to use your pension funds in a registered pension scheme to buy an annuity with LV=. We can (please tick your required option): (A) accept a full transfer where n you will then become a member of the LV Personal Pension Scheme n we ll pay you any tax-free cash (where applicable) and a lifetime annuity n we ll combine all your pension transfers into one plan Please complete sections A to F, read Sections G, H1, 2, 3. (B) accept an open market option where n you ve taken benefits (e.g. tax-free cash or drawdown) under the rules of your existing registered pension scheme, but have chosen to buy an annuity from LV= Please complete sections A to F, read Sections G, H1, 2, 3, 5 and sign Section H on page 9. n a separate policy will be set up for each pension scheme payment we receive (C) accept a scheme pension where n the trustees of an occupational pension scheme choose to buy a scheme pension with LV= Please complete sections A to F, read Sections G, H1, 2, 3. For options B and C we won t pay you any tax-free cash from this policy. Instead this will be paid by your existing pension scheme. Please tell us the number of pension funds coming to LV= to buy an annuity: If you ve already completed the medical assessment form(s) in our quote request, then you don t need to complete a new one to apply. However, if any details have changed since you completed the form, please tell us. Section A. Your personal details Annuitant s details Title Mr/Mrs/Miss/Ms/Dr/Other First name(s) in full Surname Address Daytime Telephone number (including area code) address Date of Birth / / (DD/MM/YYYY) We ll confirm your name and age using online information agencies. Where we can t, we ll ask you to provide evidence. Nationality National Insurance Number Are you male or female? Male Female What is your marital status? Single Married/Civil Partner Widowed Divorced Separated 2

3 Beneficiary s details please complete only if a Beneficiary s pension is required Beneficiary s Title Mr/Mrs/Miss/Ms/Dr/Other Beneficiary s first name(s) in full Beneficiary s surname Date of Birth / / (DD/MM/YYYY) We ll confirm your name and age using online information agencies. Where we can t, we ll ask you to provide evidence. National Insurance Number Are they male or female? Male Female Please specify their relationship to you? Spouse/Civil Partner Partner Other, please specify Section B. Payment details Please tell us where we should make your income payments, including any tax-free cash (unless you tell us otherwise). Please note that we will only make payments by BACS to a UK account in your name. Name(s) of account holder(s) Bank/Building Society name Sort code Account number Roll number (building societies only) n Please note your annuity is treated as taxable income. We ll deduct income tax under the Pay As You Earn (PAYE) system unless HM Revenue & Customs (HMRC) tell us otherwise. n If you have a P45 for the current tax year please forward parts 2 and 3 with this application to enable the correct amount of tax to be deducted. If you do not have a P45, tax will be deducted using the emergency code on a month 1 basis until HMRC notify us of your current tax code. Section C. Who would you like us to pay any death benefits to? If you have chosen this option, please tell us who you would like us to pay any death benefits that may become payable: n A lump sum or continuing payments under a guarantee period. n A value protection lump sum. Please note that for continuing payments under a guarantee period you should only nominate one person as we cannot pay an income from your annuity to more than one person. We will normally take your wishes into account. But, we will exercise our discretion as to whom we pay the death benefit. If you are buying an annuity by using your open market option, or the trustees of your occupational pension scheme are buying an annuity with LV=, you will need to check that the scheme rules allow us to use our discretion before you complete this nomination. Please speak to your intermediary if you have any questions on how the rules work. 3

4 Nomination 1 You must complete this for all cases Full name of nominated beneficiary Address Nomination 2 Only complete this where you want more than one person to receive the lump sum Full name of nominated beneficiary Address If you want to nominate more than two people to receive the lump sum please copy this page and attach the completed copy to this application form. If you wish to change your nomination in the future, please write to us to confirm this. Section D. Lifetime allowance check HMRC require us to know whether this annuity takes you over your personal Lifetime Allowance. If it does you may have to pay an additional tax charge. Are the total value of all your pension and annuity benefits including this annuity more than the Standard Lifetime Allowance? Yes No Do you have a personal Lifetime Allowance different to the Standard Lifetime Allowance, for example, enhanced protection, fixed protection or a protected early retirement age? Yes No If you re 75 or over and are taking a lump sum, is the amount that you are taking within 25% of your remaining personal Lifetime Allowance? Yes No Understanding the Lifetime Allowance rules is important because if you provide incorrect or incomplete information you may become liable to a Lifetime Allowance tax charge. If you are unsure how to calculate the value of your benefits, please refer to your financial adviser or your current provider(s). Section E. Details of funds used to buy the annuity Please complete this section for all the pension funds you re using to buy an annuity, whether you re doing this as a transfer, open market option (OMO) or scheme pension. If the pension funds are coming from more than three arrangements, please photocopy this page. Please provide full details of your registered pension schemes as this will enable us to get the funds to us as quickly as possible. If you have a Discharge/Transfer form from your pension scheme(s), please send with this application. Source 1 How are the funds arriving Transfer (LV= to pay any TFC): Please read the Declaration in Section H OMO (Pension Scheme to pay any TFC): Please read the Declaration in Section H Scheme pension (Occupational Scheme to pay any TFC) : Please read the Declaration in Section I Is the maximum tax-free cash required? Yes No If not, what percentage or value is to be taken? % Full name of the current provider/pension scheme Type of scheme, (for example Personal Pension) Name of Trustee (if applicable) Address of scheme 4

5 Telephone number of scheme Existing plan number Approximate amount of funds coming to LV= Source 2 How are the funds arriving Transfer (LV= to pay any TFC): Please read the Declaration in Section H OMO (Pension Scheme to pay any TFC): Please read the Declaration in Section H Scheme pension (Occupational Scheme to pay any TFC) : Please read the Declaration in Section I Is the maximum tax-free cash required? Yes No If not, what percentage or value is to be taken? % Full name of the current provider/pension scheme Type of scheme, (for example Personal Pension) Name of Trustee (if applicable) Address of scheme Telephone number of scheme Existing plan number Approximate amount of funds coming to LV= Source 3 How are the funds arriving Transfer (LV= to pay any TFC): Please read the Declaration in Section H OMO (Pension Scheme to pay any TFC): Please read the Declaration in Section H Scheme pension (Occupational Scheme to pay any TFC) : Please read the Declaration in Section I Is the maximum tax-free cash required? Yes No If not, what percentage or value is to be taken? % Full name of the current provider/pension scheme Type of scheme, (for example Personal Pension) Name of Trustee (if applicable) Address of scheme Telephone number of scheme Existing plan number Approximate amount of funds coming to LV= Does this represent the full value of the existing plan for each source? Yes No If no please provide details Do any of the pension funds relate to Pension Credit Rights arising after divorce under the provisions of the Welfare Reform and Pensions Act 1999? Yes No Please note that we can t accept funds with earmarking orders 5

6 Do you want any tax free cash paid, to be paid into the same account as your annuity? Yes No Please note that for open market options any tax-free cash paid by your current provider will be paid into the bank or building society account you ve given us on page 4. If you want them to pay the money into a different account instead please provide details below. Name of Bank/Building Society to which the tax-free cash is to be paid Address Account name (for example Mr Adam Smith) Sort code Account number Roll number (building societies only) Section F. Adviser Charge/Commission Intermediaries: Please complete this section for all cases. Is this an advised sale? Yes No If this is an advised sale was the advice independent or restricted If the advice was restricted, was it: Tied Multi-tied Whole of market Please complete this section if you want LV= to pay an adviser charge or commission. An adviser charge is the payment you have agreed to pay your intermediary for the advice provided to you. We won t calculate any VAT to be included in the adviser charges payable. Please include this in the amount stated if relevant. Adviser charge amount expected or % Commission amount expected or % 6

7 Section G. Important information Before your financial adviser submits your application we recommend that you should read the relevant Pension Annuity Policy Conditions and Key Features Document. This is important as this explains in detail how your spouse, civil partner or beneficiary (as applicable) will receive any benefits from the plan. By your financial adviser submitting this application you and your spouse, civil partner or beneficiary (as applicable) are confirming to have read and accepted the policy conditions, key features document, important information and declarations of the LV= Pension Annuity. General n For transfers, payment of the annuity will only begin when we accept this application form and receive the payments from the schemes or arrangements (the plan(s)) listed in Section E. Where you ve applied for us to receive multiple payments, and we receive these payments at different times, we ll pay the money received into a non-interest bearing holding account. The annuity payments won t begin until we ve received all the relevant payments from your existing registered pension schemes. For Open Market Options (OMO) and scheme pensions, we ll set up each annuity separately as we receive the payments from the schemes or arrangements (the plan(s)) listed in Section E. n The amount of the annuity we pay you may be different to the quote. We ll confirm this when we accept your application. n We may write to your doctor to confirm any medical/lifestyle information you have given. We will not ask you to have a medical examination at any time. n Within six months of the date your annuity policy is issued we ll tell you if we plan to reduce the annuity payments. This may happen if we are unable to support the medical/lifestyle information you ve given, unless further evidence is provided. If we reduce the annuity payments we ll recover any overpayments of income we ve already made. n The contract will be subject to, and governed by, the laws and jurisdiction of England and Wales. n The annuity cannot be cashed in, surrendered or assigned, except in accordance with the relevant legislation and subject to our agreement. All the information that you provide will be shared with all parties to this application. If you would like a copy of any of the relevant documents referred to below, or a copy of this completed application form, please let us know. Warning: it is a serious offence to make false statements; the penalties are severe and could lead to prosecution. Data Protection We ll keep your information and add it to our customer databases even if your application doesn t go ahead. We may use it to keep our records up to date, for business analysis and market research. We won t include you in direct marketing campaigns and we may pass your details to other carefully selected organisations, but only for the purposes listed here. Subject to payment of a fee, if you d like us to send you a copy of the personal information we hold about you, please write to: CCA Department, LV=, County Gates, Bournemouth BH1 2NF For more information about the LV= group of companies please go to n If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies to prevent fraud and money laundering. n Further details explaining how the information held by fraud prevention agencies may be used can be obtained by writing to Group Financial Crime, LV=, County Gates, Bournemouth BH1 2NF. LV= may use information given to make searches about you at credit reference agencies and other organisations that hold your information (such as from the electoral roll) to check your age and identity. The credit reference agencies and other organisations may keep records of these searches, even if the application doesn t go ahead. LV= may use scoring methods to check your identity and may ask for supporting documents. LV= may use information provided to process my application and manage my policy. The information may be kept electronically or on paper file for as long as the application is being considered, while the policy is active and for an appropriate length of time after that. I agree that LV= may provide my intermediary with any information relating to my product(s) with LV=, including personal and sensitive personal data. If at anytime I change intermediary, or want LV= to stop providing information to my intermediary, I will notify LV= directly of this. I agree that LV= can use any sensitive information I provide, such as health and medical information, to process my application and for the ongoing management of my policy. This information may be passed on to: n my GP n any medical practitioner and/or health care professional acting for LV= n reinsurers or any other insurer I ve applied and given consent to n my intermediary n any associated company of LV= 7

8 Section H. Declarations Declaration by the Annuitant Part H1 - Declarations by the Annuitant to LV= n I agree that this application form, and quote referenced on the front page, submitted by my intermediary on my behalf, is allowed within the rules of the current pension scheme or buy out policy and forms a legally binding contract with LV=, allowing an immediate request of funds from the ceding scheme(s). n I declare that to the best of my knowledge and belief the information contained in this application form and my Annuity Quote Request Form is complete and true and I have checked any answers completed on my behalf. I m aware if I ve knowingly withheld, concealed or not updated any information LV= has asked for before acceptance, this may result in my income payments being reduced. n If I decide to cancel the policy, I will return any money paid to me, within the cancellation period. n I agree that if I receive benefits (lump sum and/or income) at any time from LV= to which I m not entitled, I ll pay back any such payments n I instruct LV= to pay my intermediary the adviser charge or commission specified in this application form. If I cancel my plan within the cancellation period, LV= will claim this back from my intermediary and return the full amount of my fund to the current provider, who will decide whether to accept the return. n I agree that LV= will keep my intermediary updated throughout the application process and will accept any Instructions from them to make any changes to this application before my plan starts. n For transfers in, I apply to become a member of the LV Personal Pension Scheme and agree to be bound by its trust deed, rules, and Policy Conditions. I confirm that I ve been provided with an opportunity to select the insurance company from which to buy my annuity, and have chosen LV=. Part H2 - Declarations by the Annuitant to LV= and the current provider n I would like to take benefits from the plan(s) listed in Section E. n I authorise you to release all necessary information to LV= to enable the transfer of funds to LV=. n I authorise and instruct you to transfer the funds from the plan(s) as listed in Section E directly to LV=. n I authorise you to obtain from and release to the intermediary named in this application any additional information that may be required to enable the transfer of funds. n Until this application form is accepted and complete, LV= s responsibility is limited to the return of the total payment(s) to the current provider. n Where the payment(s) made to LV= represent(s) all of the funds under the plan(s) listed in Section E, then payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from the plan(s) listed. n Where the payment(s) made to LV= represents part of the funds under the plan(s) listed in Section E, then the current provider will be discharged of all claims and responsibilities only in respect of the part of the plan(s) represented by the payment(s). n I confirm that any adviser charge paid on my behalf by LV= on the initial set up of this annuity: Is wholly connected to the purchase of this annuity; and Is appropriate to the advice and service my intermediary provided me in relation to this annuity purchase. n If this is not the case then some or all of the Adviser Charge and any Pension Commencement Lump Sum may become liable to a tax charge, which I may be responsible for. n I confirm that: n The total value of: the pension income [and tax-free cash] I have already taken (including drawdown income and any income taken before 6 April 2006); any pension funds transferred overseas, and; the benefits I am taking now. are below the current standard Lifetime Allowance threshold of 1.25 million from the tax year 2014/15; n If I have a pension which was in payment as at 5 April 2006 and I have not already taken benefits from another scheme I will provide the current provider(s) and LV= with details of the level of income currently in payment; or; n I will notify the current provider(s) and LV= if I am, or believe I am, above the standard Lifetime Allowance threshold; 8

9 n I will advise them if I have a protection in place against the Lifetime Allowance tax charge. I will provide a copy of my HRMC protection certificate if asked to do so. n I will be solely responsible for any additional tax charges or any penalties which arise if the information provided in this application is incorrect or if I ve failed to comply with any aspect of this application. n In addition, I promise to accept responsibility in respect of any claims, losses and expenses that LV= and the current provider may incur as a result of any incorrect information provided by me in this application or of any failure on my part to comply with this aspect of this application. n Where I ve chosen to take tax free cash, it isn t my intention to make, either directly, indirectly, or by someone making contributions on my behalf, a significant increase in my total expected contributions to registered pension schemes. A significant increase is where: The total tax-free cash you receive in the 12 month period ending on the day the tax-free cash from this plan is paid, exceeds 7,500 (for the tax year 2015/16), and more than 30% of those tax-free cash sums is used to make contributions to one or more registered pension schemes which exceed the expected level of contributions. This includes any contributions you pay directly or indirectly, paid by someone on your behalf such as your employer, or which you may have paid in anticipation of receiving the tax-free cash. Part H3 - Declarations by the Annuitant to the current provider n Please pay me any tax-free cash as instructed and pay the balance of funds to LV= to provide me with an annuity on the basis set out in the quote indicated on the front of this application n Where you have asked me to give you the original policy document(s) in return for the transfer of funds and I m unable to do so, I promise that I will be responsible for any losses and/or expenses which are the result, and which a reasonable person would consider to be the probable result, of any untrue, misleading or inaccurate information deliberately or carelessly given by me, or on my behalf, either in this form or with respect to benefits from the plan Before signing the Declaration below we recomend that you should read the Pension Annuity Policy Conditions and Key Features Document. By signing below you are confirming to have read and agree to the statements in the Important Information and Declaration by the Annuitant sections. Print name Signature of Annuitant Date / / (DD/MM/YYYY) 9

10 Section I. Trustee/Scheme Administrator Declarations Declaration for and on behalf of the Trustees/Scheme Administrator of the originating occupational pension scheme or buyout policy buying a scheme pension only n I apply to LV= to issue an annuity to the annuitant named in Section A as specified in this application form and on the quote referenced on the front of this application. n I declare that to the best of my knowledge and belief, the statements in this application form are complete and true and I have checked any answers completed on my behalf. n I shall inform LV= of any change occurring before acceptance of this application form and understand that failure to do so may result in my income payments being reduced. n I agree that this application form, together with the quote referenced on the front of this application and the Pension Annuity Policy Conditions, forms the entire contract between LV= and myself. I understand that the contract will be subject to, and governed by, the laws of England and Wales. n I confirm that the annuity being applied for is consistent with the rules of the originating occupational pension scheme or buyout policy. n I instruct LV= to pay my financial adviser the adviser charges or commission specified in this application form. n I agree that my policy will start when LV= receive my completed application. n I agree to accept the annuity applied for, subject to the Pension Annuity Policy Conditions. n The percentage of the Standard Lifetime Allowance that this annuity and related tax-free cash will use up is % n I request the annuity to be issued in the name of: The scheme trustees or The annuitant, as provided for under scheme rules or buy-out policy If there is a scheme specific start date enter it here / / (DD/MM/YYYY) By submitting this application you are confirming to have read and agree to the statements in the Important Information and Declaration for and on behalf of the Trustees/Scheme Administrator of the originating Pension Scheme sections. Scheme name Signature Date / / (DD/MM/YYYY) Name(s) Position(s) 10

11 11

12 LV.com You can get this and other documents from us in Braille or large print by contacting us. Liverpool Victoria Friendly Society Limited: Keynes House, Tilehouse Street, Hitchin, SG5 2DX. LV= is a registered trade mark of Liverpool Victoria Friendly Society Limited (LVFS) and a trading style of the Liverpool Victoria group of companies. LVFS is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority, register number NM Pensions Trustees Limited, (registered in England No ), act as Trustees and Scheme Administrators. Authorised and regulated by the Financial Conduct Authority, register number Registered address for all companies: County Gates, Bournemouth BH1 2NF. Tel: /15

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