Change of Policyholder Introduction This form allows you to change the policyholder(s)/trustee(s) for a Group Life Assurance Policy for death in service benefits where the scheme only provides death in service benefits. This form should only be used where a Group Life Assurance Policy is being transferred from: (a) one or more trustees to another individual/company/limited liability partnership/partnership. For example, where the proposed new policyholder is a different company or limited liability partnership; OR (b) the trustee(s) of one trust to the trustee(s) of another trust. This form should not be used if there is only a change of name, registered office or principal address. In this case Canada Life simply needs to be advised in writing of the change. This form cannot be used if there is no authorised signatory to sign the form on behalf of the current policyholder(s)/trustee(s) or the current policyholder(s)/trustee(s) has been dissolved. In this case a new policy must be set up for the proposed new policyholder(s)/trustee(s). Where the existing trust is to remain in place the current policyholder(s)/trustee(s) will also need to amend the existing trust deed to appoint the new policyholder(s)/trustee(s). If a new trust has been established by the proposed policyholder(s)/trustee(s), full details of the new trust will be required. By completing and returning this form both the current policyholder(s)/trustee(s) and the proposed new policyholder(s)/trustee(s) agree that from the effective date of the transfer: All the rights and obligations of the current policyholder(s)/trustee(s) under the Group Life Assurance Policy will be transferred to the proposed new policyholder(s)/trustee(s). The proposed new policyholder(s)/trustee(s) will be bound by the terms of the Group Life Assurance Policy in every way as if it/they were the current policyholder(s)/trustee(s) and the Group Life Assurance Policy was originally issued to it/them. In particular, the proposed new policyholder(s)/trustee(s) will become responsible for any outstanding premiums as well as any future premiums. The current policyholder(s)/trustee(s) releases and discharges Canada Life Limited ( Canada Life ) from all its/their claims and demands arising under or in connection with the Group Life Assurance Policy. Unless agreed otherwise with Canada Life, the Group Life Assurance Policy will, in all other respects, continue on its existing terms. Trust and policy details Policy number Current trust name Current policyholder(s)/trustee(s) 1
Transfer details Effective date of transfer Reason for change of policyholder/trustee New trust name We will assume that the current eligibility and benefit basis is to remain the same and that there will be no new entrants at the date of the transfer. Please advise us if this is not the case and the details of the changes so that we can advise any additional requirements. Proposed new policyholder/trustee details A. Corporate policyholder(s)/trustee(s) Registered office (including postcode) Status Companies House registration number Company Limited liability partnership Charity registration number (if applicable) B. Individual acting as policyholder(s)/trustee(s) Address (including postcode) New contact details (if applicable) Please use an additional sheet if more than one individual is acting as policyholder(s)/trustee(s). Title Telephone Number Fax Number E-mail address 2
New trust details (if applicable) of execution of new trust deed (the date of execution is normally the date on which the last trustee signed the trust) What is the name of the new trust? Has the trust been provided by Canada Life Limited? Is the trust registered with HM Revenue and Customs (HMRC) under Chapter 2, Part 2 of the Finance Act 2004? If the trust has been registered with HMRC please give the Pension Schemes Tax Reference (Reference number format 12345678RE) Yes Yes No No Important Notes: If the trust is not registered with HMRC Canada Life will only issue an Excepted Policy as defined in chapter 480(3) of the Income Tax (Trading and Other Income) Act 2005. If the Canada Life trust deed has not been used we may not be able to assist with future documentation updates. The policy will be issued to and in the name of the trustees. Data Protection Notice Any personal information you may provide to Canada Life Limited, (referred to as Canada Life in this notice) as data controller will be treated in accordance with the Data Protection Act 1998. By signing this form you consent to Canada Life using and sharing your personal information as set out in this notice. If submitting personal information about another person, by signing this form you confirm that you have their consent to provide such information to Canada Life and for their information to be used as set out in this notice. Using personal information Canada Life uses personal information to undertake any activity relating to its policies, products and services and, where relevant, to process applications, set up and administer policies, products and services and handle any claims. Sharing personal information Canada Life may share personal information: with other companies in the Canada Life group in the United Kingdom and with those outside the European Economic Area; with any of its or their service providers, reinsurers and regulators; with other insurers; with other companies, organisations and associations and/or credit reference agencies in order to prevent, detect or investigate financial crime or fraud; for employer-related products and services, with the employer, the trustee(s) and their agents; and/or in any circumstances if permitted or required to do so by law or if Canada Life has consent to do so. Accessing personal information A person whose personal information is held by Canada Life has various rights including the right to: have any incorrect personal information corrected; and/or access the personal information Canada Life holds for which a fee may be charged. To do so and/or if you need more information, please contact Canada Life at: Canada Life Limited, 3 Rivergate, Temple Quay, Bristol BS1 6ER. 3
Notes on signing this form This form must be signed by the duly authorised representative(s). Current policyholder(s)/trustee(s) declaration From the effective date of the transfer I/we, the undersigned: transfer all my/our rights and obligations under the Group Life Assurance Policy to the proposed new policyholder(s)/trustee(s) release and discharge Canada Life from all claims and demands I/we may have under or in connection with the Group Life Assurance Policy, whether arising before, on, or after the effective date of the transfer acknowledge that Canada Life shall release and discharge me/us from all claims and demands it may have under or in connection with the Group Life Assurance Policy, whether arising before, on, or after the effective date of the transfer 4
Proposed new policyholder(s)/trustee(s) declaration From the effective date of the transfer I/we, the undersigned: declare that the information given in this form is accurate and correct confirm that I/we have read the data protection notice and am satisfied that my/our personal information will be handled appropriately, in accordance with the notice and where I/we provide personal data in relation other people, I/we have their consent to provide such information and for their information to be used as set out in the notice agree to be bound by the terms of the Group Life Assurance Policy in every way as if I/we were the original party to it in place of the current policyholder(s)/trustee(s) and the Group Life Assurance Policy was originally issued to me/us. In particular, I/we agree to be responsible for any outstanding premium owed to Canada Life as well as any future premiums acknowledge that I/we will have the right to enforce the terms of the Group Life Assurance Policy and pursue any claims and demands under the Group Life Assurance Policy against Canada Life with respect to matters arising before, on or after the effective date of the transfer acknowledge and accept that, unless agreed otherwise with Canada Life, the Group Life Assurance Policy will in all other respects continue on its existing terms acknowledge that the transfer of the Group Life Assurance Policy will not be effective until Canada Life has confirmed the transfer in writing Please return the completed form to Canada Life, 3 Rivergate, Temple Quay, Bristol, BS1 6ER. Our forms are available to download from our website: www.canadalife.co.uk/group Canada Life Limited, registered in England no. 973271. Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA CLFIS (UK) Limited, registered in England no. 04356028 is an associate company of Canada Life Limited. Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA Canada Life group consists of Canada Life Limited, Canada Life Asset Management Limited (both authorised and regulated by the Financial Services Authority), Canada Life International Limited and CLI Institutional Limited (Isle of Man registered companies authorised and regulated by the Isle of Man Insurance and Pensions Authority). All promotional material produced is approved by Canada Life Limited. GRP875 513R Canada Life Limited 3 Rivergate, Temple Quay, Bristol BS1 6ER Telephone 0845 223 8000 5