Expression of Wishes. Your details. Important notes. Completing this form. Retirement. Health. Retirement Investments Insurance Health

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1 Retirement Investments Insurance Health Retirement Investments Insurance Health Retirement Investments Insurance Health Aviva Retirement Pension Investments Insurance Death Health Benefit Expression of Wishes If you die before you have taken all of the benefits from your pension, they can be payable to someone else. If paid to an individual your death benefits can be paid as a lump sum, Flexi-access drawdown pension or an annuity. You can use this form to tell us who you would like to receive your death benefits. To ensure your death benefits do not form part of your taxable estate for inheritance tax purposes, we must exercise our discretion when deciding who is to benefit. Although we will take your wishes into account in making our decision as to who should receive your death benefit, we will not regard them as binding on us. We will treat the information in this form as an indication of whom, at the time the form was completed, you wished us to take into account in deciding who should receive your death benefits. Your details National Insurance No. Address House name Please insert details of your pension account or pension policy as appropriate: Your pension account number Your pension policy number and/or any related account created subsequent to the date of this this nomination. Important notes If you have made your pension death benefits subject to a valid trust any lump sum death benefit will be paid directly to the trustees of that trust. Completing this form In stating the proportion of the benefit that you would like your beneficiaries to receive, please make sure that the total of the proportions you enter across sections 1 to 4 equals 100%. 1

2 Section 1: Dependant beneficiaries Dependants are defined as the following: Your spouse or civil partner or, Your children (under the age of 23) or, Someone who is financially dependent or inter-dependent on you or, Someone who is dependent on you because of physical or mental impairment. If you have no dependants please don t complete this section and go to Section 2 Details of dependant 1: Relationship to you Share you would like first dependant to receive % Details of dependant 2: Relationship to you Share you would like second dependant to receive % 2

3 Details of dependant 3: Relationship to you Share you would like third dependant to receive % If you have more than three dependants, please complete their details separately and attach to this form. Section 2: Existing trust If you would like an existing trust to receive lump sum death benefits when you die, please insert details of all the appointed trustees and the percentage share you would like the trust to receive. Details of trust: Name of trust (if any) Date trust created The share you would like the trust to receive % If there is no corporate trustee, please provide details of the individual trustees: 3

4 Section 2: Existing trust continued If there are more than four trustees, please complete their details separately and attach to this form. If the trust has a corporate trustee, please provide the following details: Name of corporate trustee Section 3: Charity If you would like a charity to receive your death benefits when you die, please complete the following details and the share you would like the charity to receive. Name of charity Registered number 4

5 Section 3: Charity continued Name of charity Registered number If you would like more than two charities to receive your death benefits, please complete their details separately and attach to this form. Section 4: Non-dependant beneficiaries In this section, please give details of any non-dependant individuals you would like to receive your death benefits when you die, and the share you would like them to receive. Details of first beneficiary: Share you would like beneficiary to receive % Details of second beneficiary: Address - name/numbe Share you would like beneficiary to receive % 5

6 Section 4: Non-dependant beneficiaries continued Details of third beneficiary: Share you would like beneficiary to receive % If you have more than three beneficiaries, please complete their details separately and attach to this form. Important Notes Although we will take your wishes into account in making our decision as to who should receive your death benefit, we will not regard it as binding on us. We will treat the information in this form as an indication of who, at the time the form was completed, you wished us to take into account in deciding who should receive your death benefits. Your nomination will be disregarded by us: In respect of any named person(s) other than trustees, who die before you, or In respect of any named person who you are subsequently divorced from, or In respect of a named civil partner when the civil partnership is dissolved, or If you subsequently place the death benefits under a valid trust, or If you send us details of any changes to your nomination in writing. This nomination is not a form of trust. If you are unsure how to complete this nomination, or wish to discuss the implications of making your nomination or placing the death benefits under trust, we recommend that you refer to your adviser. We recommend that you regularly review your expression of wishes in light of any changes in your personal circumstances. This is particularly important if someone you would like to benefit dies before you, or your relationship to them changes. I confirm that I have read and agreed with Important notes, above. Print name Signature Date

7 Aviva Life Services UK Limited. Registered in England No Wellington Row, York, YO90 1WR. Authorised and regulated by the Financial Conduct Authority. Firm Reference Number aviva.co.uk LF /2016 Aviva plc