S.P. Plan Type. A.P. Plan Type. This application is to be used for employee members of Group Pension and/or Group AVC Schemes.

Transcription

1 Group Pension/ Application Form A.P. Plan Type R (as per the illustration) S.P. Plan Type R (as per the illustration) Intermediary Name Financial Advisor Name Intermediary Number Please complete in BLOCK CAPITALS. A This application is to be used for employee members of Group Pension and/or Group Schemes. Scheme Details Scheme Name Full Name of Employer Category (If applicable) Under the Criminal Justice Act, 2010, Zurich Life may require clients to provide Evidence of Identity and Proof of Address and other supporting documentation. B Details Mr Mrs Ms Surname Home Address Forename (The '') Special Instructions Date of Birth Sex M F Civil Civil Status Married Single Widow(er) Separated Divorced Partner Telephone Number (work) (home) Former Civil Partner Address Nationality Country of Residence Occupation (mobile) Number Please describe fully and if your occupation is 'Company Director' please detail the nature of the business. Annual Salary/Earnings Normal Retirement Age 1

2 C Contribution Details Regular Contributions Please complete the attached Salary Deduction Instruction in respect of employee contributions/s. Amount of Gross Regular Contribution Employer or of Salary Contribution Frequency Monthly Weekly or or Yearly Half-yearly Total or Quarterly Please attach a cheque/bank draft payable to Zurich Life in respect of any once-off contribution. Once-off Contribution* Employer Amount of Once-off Contribution * Does this once-off payment represent a transfer from another pension arrangement? Yes No. If YES, please provide details. Also, if the transfer payment is the subject of a Pension Adjustment Order (PAO) please tick here and supply a copy of the PAO. Total If you choose the PensionSTAR (ARF) investment strategy, you should note that Revenue restrictions may prevent you from investing the proceeds of your Pension Plan in an ARF at retirement. D Investment Options (continued on next page) If the scheme rules allow for employees to make their own investment choice, please complete this section. If not, please proceed to Section E opposite. Please select either 1 or 2 below. For once-off contributions, units are bought at the ruling price on a date not later than three working days following receipt of the once-off contribution and the completed application form. For regular contributions, units are bought at the ruling price on the date each contribution is due. If any contribution is not received in full on the date due, we may buy units on the day that you pay that full contribution. 1. PensionSTAR Which PensionSTAR investment strategy do you wish to follow? PensionSTAR Annuity or PensionSTAR ARF 2. Matrix Fund Choice Please specify the Matrix Fund(s) to which your policy is to be linked: Please proceed to Section E. Sector Fund Name Regular Contribution Once-off Contribution You can choose a combination of up to 10 funds for your investment. Active Management Equity Concentrated Funds 5 5 Global 5 5 Europe Employer/ Employer/ 5 5 Asia Pacific 5 5 Americas *These funds are managed by Threadneedle Investments and are subject to an additional management charge of 0.5 per annum. Geographic Funds Global Equity Funds Irish Equity Eurozone Equity Asia Pacific Equity American Select* European Select* International Equity Dividend Growth Global Select* The maximum entry age for the SuperCAPP Fund is aged 60 next birthday provided there are at least five years remaining to Normal Retirement Age. Prior approval is required from Zurich Life if the age next birthday exceeds 60. Managed Funds Active Diversified Funds Dynamic Performance Balanced Cautiously Managed Secure Active Asset Allocation Dynamic Diversified Growth Unitised With Profits Fund SuperCAPP 2 Continued overleaf

3 D Investment Options 2. Matrix Fund Choice (continued) Sector Fund Name Regular Contribution Once-off Contribution Active Management Employer/ Employer/ Fixed Interest/ Bond Funds Deposit fund Long Bond Active Fixed Income Deposit Fund Deposit Plus (Series 2) INDEX TRACKER / EXCHANGE TRADED FUNDS These funds are managed by BlackRock Investments. Geographic Funds India Equity Europe ex-uk Index Japan Index UK Index Indexed Eurozone Equity Global Equity Fund Indexed Global Equity Sector Fund TopTech 100 Commodity Funds Property Equity Funds Global Commodities Gold European (Ex-UK) Property Australasia Property Fixed Interest/ Bond Funds Strategy funds Strategy Funds Inflation-linked Bond Indexed Eurozone Government Bond Green Resources Earth Resources Diversified Assets OTHER FUNDS For this product you can only switch within the Matrix range of funds. TOTAL If you elect to transfer a retained pension benefit(s) into the pension scheme, we will assume (unless advised otherwise) that the investment strategy you have chosen in Section D 1. or 2. above will apply to the transfer value. E Revenue Information PPSN Are you a 20 Director? * Yes No Date of Entry into Service Date of Joining Pension/ Scheme * Appendix I of the Revenue Pensions Manual defines a '20 director' as someone who directly or indirectly at any time in the last three years owned or controlled more than 20 of the voting rights in the employer company, or in the parent company of the employer company. 3

4 F Retained Benefits In order to ensure that benefits and contributions are within Revenue Limits, we need details of current and previous pension benefits known as retained benefits. Retained Benefits: mean relevant benefits (pension and lump sum) provided for the member under other schemes including the Main Scheme whether deferred or already in payment. Included are: (i) Approved or statutory schemes relating to previous employments; (ii) Buy-out Bond policies held in respect of entitlements relating to previous employments; (iii) Retirement Annuity Contracts (Personal Pensions); (iv) Personal Retirement Savings Accounts (PRSAs); (v) Schemes relating to overseas employment. The following benefits may be ignored when calculating retained benefits: (i) Small deferred pension not exceeding 330 per annum. (ii) Small lump sums not exceeding 1,270 in aggregate. (iii) Refunds of contributions. (iv) Benefits under statutory or approved schemes or under Retirement Annuity Contracts relating to concurrent employments. The concept of retained benefits also applies as regards maximum death-in-service benefits. 1. If applying to make s, are you a member of the Main Scheme? 2. Have you ever effected an approved Retirement Annuity Contract (i.e. Personal Pension/Self-employed Pension Policies or Personal Retirement Savings Accounts (PRSAs)) in respect of a previous non-pensionable employment or while self-employed? 3. Are you and/or your dependant(s) entitled to benefits from other Retirement Benefit Schemes? Yes Yes Yes No No No If the answer to questions (2) or (3) is YES, please give details below (continue on a separate sheet, if required). Please include details of all retained benefits, including immediate and deferred pensions for you, your spouse and dependants, and lump sums and gratuities payable on death, retirement and leaving service. Please also advise if any of these benefits are subject to a Pension Adjustment Order arising from a judicial separation or divorce. Details of any retirement benefits payable from any source including those from outside the Republic of Ireland to be included here. 4

5 Please ensure that you sign the appropriate box at the bottom of Part B below. G Declarations by Part A Data Protection & Revenue Commissioners' Declaration I authorise the Department of Social Protection or the Revenue Commissioners to advise Zurich Life Assurance plc ( Zurich Life ) of my most recent address on their records at any future time. Zurich Life or its authorised agents, may hold, use, disclose and process any information provided by me ( data ), which shall include information contained in this application (or provided subsequently in discussion or otherwise) and any information arising in relation to the Plan and the policy, in order to: process this application, manage and administer the Plan and the policy; provide data to any of the companies that make up the Zurich Financial Services group (the 'Group') to enable them to do so; and provide data to my Intermediary/Financial Advisor to enable them to administer the Plan and the policy; comply with legal and regulatory obligations; overview and analyse the Plan and the policy regularly for Group reporting; communicate with me (subject to legislation) by post, telephone, or SMS unless instructed not to by me in writing; disclose the data to any (or any proposed) assignee, disposee, successor, reinsurer or transferee of my entitlements under the Plan; disclose/transfer the data abroad (subject to legislation) for the above purposes to persons approved of by Zurich Life; and check my personal data against international trade/economic or financial sanctions laws or regulations listings. You have a right of access to and the right to rectify the data concerning you held by Zurich Life/the Group. Zurich Life may, in future, want to use your data to tell you about its products and services, those of the Group or of a third party that they have arranged for you. If you do not want your data to be used for these purposes, please tick here. You can ask Zurich Life/the Group at any time to stop using your data in this way, by writing free of charge to Customer Services, Zurich Life Assurance plc, Zurich House, Frascati Road, FREEPOST, Blackrock, Co. Dublin. Part B I have read the product information provided in respect of the Plan and I confirm the investment strategy selected. I declare that the statements in this application are true and complete (including any statements written down at my dictation), and I agree that this declaration shall be the basis for the proposed Plan and the policy with Zurich Life. If the policy was sold, signed or completed outside Ireland, insert the name of the country where it was sold, signed or completed. I consent to Zurich Life or the Trustee seeking information and benefit details from the administrator, trustees or other relevant insurance office 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 also consent to any deduction of contributions set out in this application form. I confirm that I have read and fully understand all parts of the above declaration and that I will be the beneficial owner of any benefits payable in accordance with the trust deed and rules. : Please sign and date. Signature of X Date Continued overleaf 5

6 Nomination Form (do not detach) I request that the Trustee considers paying or applying any lump sum payable on my death in service to or for the benefit of the following persons in the following proportions: To be completed by. Name Relationship, if any (wife, father, sister, etc.) Address Proportion () Please use BLOCK CAPITALS. The people specified might include your spouse/civil partner, your relatives, people who are financially dependent on you, and people mentioned in your will. You may, however, specify anyone you wish. People who receive lump sum benefits on your death may have to pay tax. More information on this tax can be obtained from the Revenue. If your circumstances change, for example if you get married, you should consider if you wish to obtain and fill in a replacement form. The Trustee is not bound by the preferences that you indicate on this form, and the Rules of the Plan allow for the Trustee to dispose of the lump sum in a different manner. This notification replaces any former notification that I have issued to the Trustee. Full Name (Print): : Please sign and date. Signature of X Date 6

7 Salary Deduction Instruction Do not submit this instruction to Zurich Life. It should be detached and given to your Employer. To: Personnel Officer of Employer s Agreement and Authority to Deduct / Contributions (to be retained by Employer) Please deduct from my gross salary until further notice the appropriate gross amount agreed by me in Section C, on the appropriate dates, in respect of my contributions and any increases in contributions under the Group Pension/ Scheme and remit this amount to Zurich Life Assurance plc. : Please sign and date. Signature of X Name BLOCK CAPITALS Date / Personnel Number Pay Group/Payroll Number Department Location

8 Print Ref: PP Product Ref: PAF, PAV, QAD, QAQ, PAE, PA1, PA4, PA8, PAU, PBP, QAC, QAP Zurich Life Assurance plc Zurich House, Frascati Road, Blackrock, Co. Dublin, Ireland. Telephone: Fax: Website: Zurich Life Assurance plc is regulated by the Central Bank of Ireland. Intended for distribution within the Republic of Ireland. The information contained herein is based on Zurich Life s understanding of current Revenue practice as at March 2012 and may change in the future.