CONDUCTOR SAVINGS & INVESTMENT PLAN APPLICATION FORM

Transcription

1 CONDUCTOR SAVINGS & INVESTMENT PLAN APPLICATION FORM AGENCY USE: Agency No. Agency Name OFFICE USE: Savings Plan ZSR Contract No. Client No. Investment Plan ZSS Please complete this application in BLOCK CAPITALS and tick any relevant boxes. Once you have submitted this application you may ask for a copy to be sent to you. SECTION 1 PERSONAL DETAILS Full Name of First Life: Full Name of Second Life: Mr. Mrs. Ms. Mr. Mrs. Ms. First Name(s) First Name(s) Surname Surname Address Address of Birth of Birth Country of residence Country of residence Contact Number Contact Number IMPORTANT NOTE In accordance with Statutory Instrument No. 641 of 2011 Return of Payments (Insurance Undertakings) Regulations, 2011, You, as beneficial owner of this policy are required to; Provide your PPS Number in the space provided below (all beneficial owners of this policy must provide this);and You must provide satisfactory proof of your PPS number(s) e.g. Copy of P60, certificate of tax free allowance or any other document issued by the Revenue Commissioners or any other Government Department which includes details of your PPS Number and either your home address or employer details. PPS Number PPS Number (Owner 1) (Owner 2) For Office use only: Evidence of PPS Number provided in each case above AF319, Feb. 16

2 SECTION 1 PERSONAL DETAILS (CONTINUED) DETAILS OF THE CONTRACT OWNERS (if different to above) Full Name of First Life: (If policy isn t owned by an individual(s) then insert owner name) Mr. Mrs. Ms. Full Name of Second Life: Mr. Mrs. Ms. First Name(s) First Name(s) Surname Surname Address Address of Birth of Birth Country of residence Country of residence Contact Number Contact Number Unless you instruct us otherwise, we will send all correspondence to the address of the first person named above. SECTION 2 SAVINGS AND INVESTMENT CONTRIBUTIONS SAVINGS CONTRIBUTIONS Contribution Basis Level Savings Indexed Savings Contribution Amount (minimum 150 p.m. or 1,800 p.a.) Contribution Frequency Additional Lump Sum Contribution Monthly (If your Lump Sum is greater than 15,000.00, then it may be processed as a separate Investment Contribution below) Note for guidance: The Savings Plan is most suitable if you are saving for a minimum of 5 to years. It has no maximum term. INVESTMENT CONTRIBUTIONS Investment Contribution (minimum 10,000.00) (all contributions are paid by Direct debit mandate) Note for guidance: The Investment Plan is most suitable if you are saving for a minimum of 5 to years. It has no maximum term. SECTION 3 REGULAR WITHDRAWAL (Conductor Investment plan only) You may take a regular withdrawal from your investment plan. The savings plan does not offer this option. Regular withdrawal required Yes No Amount of withdrawal (minimum 100 p.m. or 500 p.a.) Frequency of payment Monthly Annually Withdrawal Basis Gross Net (Gross or Net of Tax and Exit Charges, where relevant) All payments are paid into your Bank Account. The option to receive your withdrawl by cheque is not available. Name of Account Holder Address of Account Holder IBAN Account Number BIC Code

3 SECTION 4 FUND CHOICE Passive Fund Management G Managed Funds Consensus Global Equity Funds Indexed Global (Ex Euro) Equity Indexed World Equity Indexed Eurozone Equity Indexed 50/50 Equity Indexed US Equity Indexed UK Equity Indexed Emerging Markets Indexed Eurozone Corporate Indexed Eurozone Long Bond Indexed Eurozone Government Physical Gold Managed Funds Managed New Ireland Managed Global Equity Funds International Equity KBI Global High Yield Equity Regional Equity Funds Eurozone Equity KBI Eurozone High Yield Equity Irish Equity Explorer - Emerging Markets KBI Emerging Markets High Yield Interest European Long Bond European Corporate Bond Index Linked Commodities Optimum Yield Property Irish Commercial Property UK Select Cash Cash Deposit Stewardship (Ethical) Protected Equity + Calm Euro Equity Insight Currency Market Neutral Equity Multi Strategy Global Bond Magnet Cautious Magnet Stable Magnet Portfolio Magnet Adventurous Compass Cautious Compass Stable Compass Portfolio Compass Adventurous Regional Equity Funds Interest Funds Commodities Active Fund Management G Interest Funds Specialist Funds C Specialist Equity Funds Absolute Return Strategies Portfolio Funds Magnet Range Magnet Range C Compass Range C Compass Range SDIOoo Other SDIO Self Directed Investment Option Self Directed Investment Option Fund Warnings: 1. Performance Fees: The growth of the Insight Currency fund will be subject to a 20 monthly performance fee which only applies when the growth rate exceeds p.a. The Market Neutral Equity fund will be subject to a performance fee of 10 of any growth achieved above cash returns (specifically 3-month EURIBID). 2. The price protection on the Protected Equity+ Fund, Series 3 is provided by Deutsche Bank AG. 3. Money invested in the Deposit fund is placed with one or more Banks. The payment of interest and security of capital is provided by the Bank(s). The Bank(s) and not Friends First are providing the security on the Deposit fund. Please refer to the Fund Factsheet. 4. The property fund managers reserve the right to place a withdrawal limit or/and to defer encashment for up to six months or such time as is necessary to facilitate the sale of assets if required.

4 SECTION 5 DECLARATIONS PART A: DECLARATION UNDER REGULATION 6(3) OF THE LIFE ASSURANCE (PROVISION OF INFORMATION) REGULATIONS, WARNING If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance intermediary. Ref: Policy Number: Declaration of Insurer or Intermediary: I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, (the client) has been provided with the information specified in Schedule 1 to those Regulations and that I have advised the client as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction, and of possible financial loss as a result of such replacement. Signature on behalf of Insurer or Insurance Intermediary Declaration of Client/Policyholder: Name of insurer or insurance intermediary I confirm that I have received in writing the information specified in the above declaration. Life 1 Life 2 (If relevant) PART B: COMMON REPORTING STANDARDS SELF CERTIFICATION Please note: This section should be completed for individual policy Owners only. If the policy owner is a company, partnership or other legal entity, a separate Common Reporting Standards Entity Self Certification Form will be required (this form is available for download on Broker first). If you have any questions on this section, or defining your tax residency status, please speak to your financial advisor, tax advisor or domestic tax authority. Regulations based on the Common Reporting Standards require Friends First Life Assurance Company to collect and report certain information about a policy owner s tax residence. The information provided below, together with information provided elsewhere on this form, may be shared with the tax authorities in Ireland and exchanged with tax authorities of any other country in which you are a tax resident pursuant to intergovernmental agreements to exchange financial account information. If you require further information on the Common Reporting Standard please refer to the Automatic Exchange of Information webpage on Policy Holder 1 Policy Holder 2 Are you tax resident in a country other than Ireland or Yes No Yes No the United States of America. If you have answered YES to the above, please complete the following table. Policy Owner 1 Policy Owner 2 Country of Tax Residence Tax Identification Number Country of Tax Residence Tax Identification Number Country of Birth City of Birth Country of Birth City of Birth PART C: POLICYHOLDER DECLARATION I/We submit this application, along with any subsequent information provided in relation to this application, verbally or otherwise, by me/us or the agent acting in the sale of this policy, with a view to entering into a contract for the benefits set out herein. I/We understand that the policy will commence on the commencement date indicated on the policy or on such other date as notified by Friends First. I/We understand that terms and conditions will apply. I/We have read over the replies to all questions in this application and declare that to the best of my/our knowledge and belief, all information given is true I/We consent to Friends First, verbally or otherwise, seeking and receiving additional information from me/us or my/our agents where this information has not been provided on the application or where further information is required in order to process the application and such information will be deemed to be incorporated into this application. I/We undertake to inform Friends First of any change in my/our country of residence, including my /our country or countries of tax residence, during the life of the policy. I/We understand that in the interest of customer service and to ensure the accuracy of records, telephone conversations between Friends First and me/us may be recorded. Life 1 Life 2 (If relevant)

5 SECTION 5 DECLARATIONS (CONTINUED) PART D: DATA PROTECTION DECLARATION Friends First Life Assurance Company Limited ( Friends First ) or its authorised agents may hold, use, disclose and process any information provided by me, which shall include the information held within this application and any subsequent information, provided verbally or otherwise, during the course of our relationship, in order to: 1. process, manage and administer my policy 2. communicate with me by post, telephone or 3. comply with legal and regulatory requirements 4. disclose data to any policyholder, life assured, beneficiary, trustee, assignee, successors, company within the Achmea/Friends First group or to any agent acting on my behalf, or to other disclosees as notified to the Data Protection Commissioner s Office and maintained on the Public Register available from that office. I am aware that I have the right of access to my personal data and the right to rectify my data if it is inaccurate or has been processed unfairly. I acknowledge that the information contained in this form and information regarding me and any of any of my Friends First policies may be provided to the tax authority in Ireland and exchanged with tax authorities of another country or countries in which I am tax resident pursuant to intergovernmental agreements to exchange financial account information. Your personal data may also be used to send you details about other similar services available from Friends First Life Assurance Company Limited. If you do not wish to avail of this service, please tick this box. Life 1 Life 2 (If relevant) PART E: REGULAR AND SINGLE CONTRIBUTIONS This Section only needs to be completed if: - the regular annual contribution (including your regular and additional lump sum contribnutions) exceeds 5,000.00, or - the lump sum investment contribution exceeds 20, INFORMATION REQUIRED PURSUANT TO THE CRIMINAL JUSTICE (MONEY LAUNDERING & TERRORIST FINANCING) ACT 2010 Please note, the below information is being collected solely to comply with the requirements of the Criminal Justice (Money Laundering & Terrorist Financing) Act For this reason, and in accordance with our obligations under the Data Protection Act 1988, as amended this information will not be used in any way to determine the suitability of this product to your financial circumstances. We strongly advise that you speak with your Financial Advisor for the purpose of assessing your financial circumstances or providing advice. Please state the source of wealth for this investment Inheritance Savings* Gift Sale of assets Other ** *If you have selected savings as source of wealth, please provide the following information: Employment status: Employed Yes No Gross Annual Income: 0-50,000 50, ,000 Self Employed Retired 100, , ,000 + **If you have selected other as source of wealth, please provide further details below. If you are using a bank draft to pay your premiums, please provide the following details for the account from which the payment originated. (Please ensure all fields are completed) Name of Account Holder Address of Account Holder City/postcode Country IBAN Account number BIC Code

6 SECTION 6 SEPA DIRECT DEBIT MANDATE Unique Mandate Reference (UMR): Originator s ID number: I E 6 S D D By signing this mandate form, you authorise (A) Friends First Life Assurance Company Limited to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Friends First Life Assurance Company Limited. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank. Please complete all the fields marked *. *Name of Account Holder *Address of Account Holder *City/postcode *Country *IBAN Account number: *BIC Code: Type of payment: Recurrent payment: By signing this mandate form, you authorise Friends First to provide at least 4 days advance notice before the first direct debit is collected from your account. *Name of account to be debited: Joint Account 1st Account Holder 2nd Account Holder *Signatures for Joint Accounts requiring two signatures: 1st Signature : 2nd Signature : *Name of account to be debited: Single Account Account Holder: * I confirm that only my signature is required on this account Signature: : * Policyholder s name, if different from name of account to be debited: Please return this mandate to Friends First Life Assurance Company Limited and not your bank: Creditors Name: Friends First Life Assurance Company Limited. Creditors Address: Friends First Life Assurance Company Limited Premium Collection Department, Cherrywood Business Park, Loughlinstown, Dublin 18.

7 SECTION BROKER USE ONLY SAVINGS PLAN - OPTIONS Regular Contributions Financed Option Non-Financed Option Initial Renewal (p.a.) 0 to 4.00 n/a n/a Flat rate (p.a.) n/a 0 to 5 Fund Based (p.a.) 0 to to 0.5 Office Code: Internal Use IC FOPT STD (I230) 1FR NFOPT STD (I231) Fund Management Charge (p.a.) 0.65 lowest* Plan Management Charge (p.a.) 0.50 Reduction in total charge (p.a.) 0.00 Early exit charge 3, 2, 1 Policy Fee 3.50 p.m. may increase , 2, p.a. If the regular contribution is higher than 3, per month, the Non-financed Option must be selected. Additional Lump Sum Contributions 0 to 3.50 If the additional lump sum contribution is higher than 15,000.00, then it may be set up separately under an Investment Plan. INVESTMENT PLAN - OPTIONS Lump Sum Contributions Financed Option A Financed Option B Financed Option C** Financed Option D** Non-Financed Option Amount Initial 0 to to to to to 3.50 Fund Based (p.a.) 0 to to to to to 0.5 Office Code: Internal Use 1SP FOPTA (S353) 2SP FOPTB (S354) FOPTC PMCO: 25 EEC0 CBK3 (S360) FOPTD PMCO EEC0 CBK3 (S361) 3SP NFOPT STD (S355) Fund Management Charge (p.a.) lowest* Plan Management Charge (p.a.) Reduction in total charge (p.a.) Early exit charge Policy Fee may increase , 4, 3, 2, 1 3, 2, 1 N/A N/A , 2, p.a. *The Fund Management Charge quoted above of 0.65 represents the annual charge for our Passive Funds. The actual Fund Management Charge can range up to 2 and may carry performance charges depending on the fund selected. **There is a maximum combined investment of 100,000 into Financed Options C & D. Additional Instructions:

8 Friends First Life Assurance Company Ltd Friends First House Cherrywood Business Park Loughlinstown Dublin 18 Friends First Life Assurance Company Limited is regulated by the Central Bank of Ireland. In the interest of customer service and to ensure the accuracy of our records calls will be recorded and monitored.