1 Retirement Options ESI-Tran Buy-Out Bond Personal Retirement Bond 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 ESI-Tran Buy-Out Bond and are confirming the Retirement Options selected. There are 7 Retirement Options from which to choose and these are listed below. Please read this form carefully and seek independent financial advice, if required. Zurich Life - ESI-Tran Buy-Out Bond - Policy Number(s) Please list below your Zurich Life ESI-Tran Buy-Out Bond Policy Number(s). All Pension Polices relating to the same employment must be matured at the same time. Zurich Life - ESI-Tran Buy-Out Bond Policy Number Maturity Value Investment Notice Please note that on receipt of this Retirement Options claim form the proceeds of your Zurich Life ESI-Tran Buy-Out Bond 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. Policyowner Details Title : Mr / Mrs / Ms / Other: Forename: Surname: Date of Birth: Please provide a copy of your original birth certificate (and Marriage Certificate if applicable), passport or driving licence. PPS Number: Address: Contact phone numbers: Home Work
2 Retirement Options - (All Benefits are subject to Revenue Maximum Allowable Limits) 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 7, 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 Zurich Life will calculate the maximum allowable Retirement Lump Sum. If the Retirement Lump Sum is to be calculated and paid using the Formula based on Salary, Years of Service and Retained Benefits, please insert the words Salary / Service in the space below (*). If eligible, you may avail of the Approved (Minimum) Retirement Fund A(M)RF Options if required. In this situation you can choose to take a Retirement Lump Sum of up to a maximum of 25% of the Maturity Value. Please refer to the Flowchart below and answer the following Eligibility Questions. Eligibility Questions 1) Was the original scheme that transferred to your ESI-Tran Buy-Out Yes / No Bond a Defined Contribution (DC) Scheme? 2) Did you leave service after 6th February 2011? Yes / No 3) At the time of leaving, had the Trustees of the Defined Contribution Yes / No (DC) Scheme amended the Scheme Rules to allow the ARF options for members leaving after 6th February 2011? 4) Were you a 5% Proprietary director at any stage within 3 years of Yes / No leaving service? 5) Was any part of the original Transfer Payment to the ESI-Tran Buy- Yes / No Out Bond related to your Additional Voluntary Contributions (AVC's)? If you are eligible to do so and wish to avail of the ARF/AMRF (Option 2) or the Taxable Cash Sum (Option 4) you may take up to a maximum of 25% of the Maturity Value as a Retirement Lump Sum. Please insert the required Percentage in the space below (**). If the Retirement Lump Sum option is to be waived, please insert the words Not Applicable in the space below (*). Note: If you are maturing an Additional Voluntary Contribution (AVC) arrangement, we will need confirmation from the Trustees of the main scheme of the level of Retirement Lump Sum and/or annuity/a(m)rf payable to you from the Main Scheme. I hereby request Zurich Life to issue me with a Retirement Lump Sum Payment of (*) or (**)% of the maturity value (Max Allowable is 25%)
3 Flowchart Eligibility for Approved (Minimum) Retirement Fund A(M)RF Options from an ESI-Tran Buy-Out Bond START Was the Original Transferring Scheme a Defined Benefit (DB) Scheme? If not a Defined Benefit (DB) Scheme, then the Scheme was a Defined Contribution (DC) Scheme. Did you leave the DC Scheme and become entitled to a preserved benefit after 6 th February 2011? Were you a 5% Director? Were the Rules of the DC Scheme modified to allow the A(M)RF option? Did part of the Transfer Payment relate to AVC Contributions? Transfer Payment Employee and Employer Portion of Transfer Payment Additional Voluntary Contribution (AVC) Portion of Transfer Payment RESULT - Approved (Minimum) Retirement Fund A(M)RF Option is NOT available (Apart from AVC Fund which can go to A(M)RF. Main Scheme (and AVC) Retirement Lump Sum can ONLY be based on Salary and Service Formula (and not 25% of Fund). RESULT - Approved (Minimum) Retirement Fund A(M)RF Option is available. Retirement Lump Sum can be based on Salary and Service Formula OR up to a maximum of 25% of Fund (Except AVC portion of fund if Main Scheme benefits based on Salary and Service) YES NO
4 Maximum Allowable Retirement Lump Sum Payment The total maximum allowable Retirement Lump Sum Payment from all sources for each individual 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 by you 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 Payment(s) 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 ESI-Tran Buy-Out Bond Plan, will you 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 by you 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) Details of all other Pension Benefits and Retirement Lump Sum Payments, including Details of Retained Benefits Please provide full and complete details of the following:- 1) Contract(s) from other providers being matured in relation to the same employment. 2) Retained Benefits (i.e. benefits from previous employment including any personal pension plans, PRSA s etc). This information should include details of any Retirement Lump Sum and Pension Benefit entitlements - paid or payable. This information should also include details of all current Pension Benefits and Retirement Lump Sum Payments taken by you since 7th December 2005 (please use a separate sheet if necessary). If None, then please write None. This information is needed so that we can ensure that all benefits do not exceed the maximum permitted by the Revenue Commissioners.
5 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). Name of Employer, if applicable 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 by you since 7 th December 2005.
6 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 7 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 the current AMRF and Guaranteed Lifetime Income requirement are satisfied at every subsequent maturity / retirement from a ESI-Tran Buy-Out Bond Plan (Option 2) and also prior to exercising the Taxable Cash Payment (Option 4). 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) in your name 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 in your name 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 Invest in ARF/AMRF with Zurich Life I instruct and authorise Zurich Life to invest / % of the maturity value in a Zurich Life Approved (Minimum) Retirement Fund A(M)RF in my name 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 3 - Purchase of an Annuity from Zurich Life I instruct and authorise Zurich Life to invest / % of the maturity value to purchase an Annuity in my name from Zurich Life as per the instructions given on the enclosed Zurich Life Annuity Application Form.
7 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 Note: The annuity rate and, as a result, the pension payable to you will depend on your decisions with regard to a number of factors as shown below. For example, if you opt for a spouse s annuity to be paid on your death (i.e. joint life annuity), the annuity rate will be less than if you opt for an annuity payable solely to you (i.e. single life annuity). It is important that you are satisfied with the annuity that you purchase, because once the purchase is made, the terms cannot be altered. Your financial advisor or Zurich Life will provide you with details of the effects of the different options you may wish to consider. 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. You should 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 D. 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 4 - 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. You should 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 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.
8 Option 5 - 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. You should 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 D. 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 6 - 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 7 Transfer to an A(M)RF other than with Zurich Life I instruct Zurich Life to transfer or % of the maturity value for investment in an ARF / AMRF in my name. Details as follows: Life Office or QFM / Payee Name Address / Cheque Destination
9 Contact Name / Phone Number AMRF & ARF / Policy Reference Number Pension Adjustment Order or Notice to Trustees In relation to any of the Zurich Life ESI-Tran Buy-Out Bond Plan(s) 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 ESI-Tran Buy-Out Bond(s)? Yes / No 2) A Notice to Trustees has been issued in respect of any the ESI-Tran Buy-Out Bond(s)? 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 ESI-Tran Buy-Out Bond(s). Declarations by Policyowner (to be completed in all cases) 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 Zurich Life ESI-Tran Buy-Out Bond 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) Policyowners 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 declaration shall be the basis for payment of benefits from my ESI-Tran Buy-Out Bond(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
10 200,000 and 575,000 as detailed in Option 1 Retirement Lump Sum. I understand that the above payments represent the full and final discharge of all claims and liabilities in respect of the Member. I confirm that I have read and fully understand all parts of the above Declaration. ESI-Tran Policyowner Name (Please Print) : Signature: Date: Witness Name (Please Print): Signature: Date: Position or Relationship to ESI-Tran Policyowner:
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