Zurich International Portfolio Bond. Application form for corporate organisations

Zurich International Portfolio Bond Application form for corporate organisations

Application checklist Both you and your adviser must complete this application form in the appropriate place and sign the relevant declarations. Please review the sections you need to complete, then tick the Complete circles as you finish each section. Customer section Section 1 Your application Complete the relevant part of this section. Required Complete Section 2 Organisation details Complete all of this section. Section 3 Authorised signatories Complete all of this section. Section 4 Personal details Complete all of this section if the lives lives insured insured are not authorised signatories. Section 5 Investment details Complete all of this section. Section 6 Currency details Complete all of this section. Section 7 Death benefit Complete this section if you want to remove standard death benefit. Section 8 Source of investment Complete all of this section. Section 9 Investment instructions Complete all of this section. Section 10 Fund declaration Your adviser will tell you if you need to complete this section. Section 11 Discretionary asset Read and sign this section if you manager nomination wish to nominate a discretionary asset manager to manage the assets in your plan. Section 12 Regular withdrawals Complete this section if you want to take regular withdrawals. Section 13 Zurich Portfolio option Complete this section if you nominate to have the plan assets managed within a Zurich Portfolio. Section 14 Plan declaration Read and sign this section. Section 15 Adviser authority Read and sign this section with your adviser if you want your adviser to act on your behalf. Adviser section Section 16 Adviser details Completed by your adviser. Section 17 Corporate confirmation of Completed by your adviser. verification of identity certificate (CVI) Section 18 Confirmation of verification Completed by your adviser. of identity certificate (CVI) Additional requirements (may not be required in every case) Cheque payable to Zurich Additional source of investment if more than one payment source Additional confirmation of verification of identity if more than four parties to the plan Certified power of attorney & associated completed CVI Completed photocopied pages 2

Important notes Completing this application You should complete this application with your adviser who will be able to explain each section. The application checklist on page 2 shows the sections you must complete, and the sections you may need to complete, depending on your preferences. The Zurich International Portfolio Bond (the plan) is provided by Zurich Life Assurance plc, a member of the Zurich Group. Where we refer to Zurich in this application, we are referring to Zurich Life Assurance plc. Data protection Zurich is committed to ensuring that the way we collect, hold, use and share information about you complies fully with the Irish Data Protection Acts 1988-2003. Before completing this application you should read a copy of our leaflet Your privacy is important to us as this explains how your data will be used. If you don t have a copy of our leaflet or would like more information please ask your adviser. 1 Your application Always complete this section. Please make sure you complete all relevant sections and return your application form to Zurich Life Assurance plc at Zurich Centre, PO Box 1076, Bishops Cleeve, Cheltenham, Gloucestershire GL50 9NR, UK. This form is for the life insurance version of the Zurich International Portfolio Bond and should be used for applications from: UK incorporated companies UK registered limited liability partnerships and partnerships. Is this application for a new plan or an additional payment to an existing plan (please tick)? A new plan An existing plan If the application is for an additional payment to an existing plan, please write your existing plan number below. You will not need to complete the authorised signatories or personal details sections unless there is a change in your circumstances. If you have been given a payment reference by Zurich for an electronic payment, please enter the number here. 3

2 Organisation details Organisation name Company/LLP registered number (if none, please write none ) Registered address should be provided for a UK registered company or limited liability partnership. Trading address should be provided for a partnership. Registered or trading address (if no registered address) Correspondence address (if different to above) of incorporation, or if not incorporated, country where trading of residence Telephone number Email address All authorised signatories must sign any instruction for Zurich to carry out a transaction on behalf of the organisation. 3 Authorised signatories Complete this section if you are applying for a new plan on behalf of the organisation, or changing the personal details of the authorised signatories. How many authorised signatories are there? How many lives insured are there? We will require written confirmation for and on behalf of the organisation, confirming the appointment of the authorised signatories detailed in this application, for example a board resolution or a letter signed by all partners. First authorised signatory Is this person also a life insured? Yes No Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation Second authorised signatory Is this person also a life insured? Yes No Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation 4

Authorised signatories (continued) First authorised signatory (continued) Contact details Current residential address Second authorised signatory (continued) Contact details Current residential address Please provide us with at least one contact number. Daytime telephone Mobile telephone Evening telephone Daytime telephone Mobile telephone Evening telephone At least one of the lives insured must be aged 79 or less; the minimum age is three months. We cannot set up a bond for any applicant who is a US national. Email address of birth Sex Male Female Nationality Email address of birth Sex Male Female Nationality Town/city of birth Town/city of birth of birth of birth of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) 5

If there are more than four authorised signatories please complete their details on a photocopy of this page and ensure it is returned with the application. Each additional authorised signatory must also sign a copy of the declarations. Authorised signatories (continued) Third authorised signatory Is this person also a life insured? Yes No Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation Fourth authorised signatory Is this person also a life insured? Yes No Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation Contact details Current residential address Contact details Current residential address Please provide us with at least one contact number. Daytime telephone Mobile telephone Evening telephone Email address Daytime telephone Mobile telephone Evening telephone Email address At least one of the lives insured must be aged 79 or less; the minimum age is three months. We cannot set up a bond for any applicant who is a US national. of birth Sex Male Female Nationality Town/city of birth of birth of birth Sex Male Female Nationality Town/city of birth of birth of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) 6

The maximum number of lives insured is ten. 4 Personal details lives insured Complete this section if you are applying for a new plan and the lives insured are not the same as the authorised signatories. Life insured Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation Life insured Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation Contact details Current residential address Contact details Current residential address Please provide us with at least one contact number. Daytime telephone Mobile telephone Evening telephone Email address Daytime telephone Mobile telephone Evening telephone Email address At least one of the lives insured must be aged 79 or less. The minimum age for a life insured is three months. of birth Sex Male Female Nationality Town/city of birth of birth of birth Sex Male Female Nationality Town/city of birth of birth of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) 7

If there are more than four lives insured please complete their details on a photocopy of this page and ensure it is returned with the application. Personal details lives insured (continued) Life insured Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation Life insured Surname Forename(s) Mr Mrs Miss Ms Dr Other (please give details) Position in organisation Contact details Current residential address Contact details Current residential address Please provide us with at least one contact number. Daytime telephone Mobile telephone Evening telephone Email address Daytime telephone Mobile telephone Evening telephone Email address At least one of the lives insured must be aged 79 or less. The minimum age for a life insured is three months. of birth Sex Male Female Nationality Town/city of birth of birth of birth Sex Male Female Nationality Town/city of birth of birth of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) of residence for tax purposes Tax reference number (if UK, please supply your national insurance number) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) Are you a US citizen? Yes No Normal country of residence Correspondence address (if different to current residential address) 8

Please refer to the information leaflet for details of the minimum amounts for an initial payment and any additional payment. 5 Investment details Complete this section for new plans and additional payments to existing plans. Please confirm the currency for your payment sterling $ US dollars euro Please confirm the amount you would like to invest Payment method Please confirm the payment method Cheque (including banker s draft) please make payable to Zurich CHAPS/TT Your bank may charge you a fee for a CHAPS/TT payment BACS BACS will take a minimum of three working days to reach the Zurich account If you are paying by CHAPS/TT or BACS, you will need to contact Zurich on 0370 850 6130 for a payment reference. Please make sure you write this payment reference in the Your application section (section 1). This will ensure we can match up your payment with your application. 6 Currency details Complete this section if you are applying for a new plan. Please confirm the currency or currencies you would like us to use by ticking the relevant currency. sterling $ US dollars euro The same currency for all or different currencies (please select below) Base currency* (this determines the currency in which your plan is valued and charges are deducted) Benefit currency* (this determines the currency in which regular withdrawals will be paid) * To nominate the Zurich Portfolio option, your base and benefit currencies must be sterling. Removing standard death benefit will reduce the yearly charge. 7 Death benefit Complete this section if you are applying for a new plan. Do not complete if you are making an additional payment to an existing plan or if the youngest life insured is aged 70 or over. Would you like to remove the standard death benefit? Yes No If you do not answer this question, standard death benefit will apply. If you remove the standard death benefit, the plan will continue to provide a lower level of protection. Please refer to the key features document for further details. 9

8 Source of investment This section must be fully completed in all cases A separate source of investment section is required for every different investment source. The information requested is necessary to comply with the provisions of the current financial services regulations. Where has the investment come from? Please tick the appropriate source, or use other to give details. Profits Sale of assets Dividends Sale of business Other (please specify) Other details Yearly profit or turnover Type of business Bank details of account holder of bank/building society Account number account is based in Please make sure a CVI (see sections 18 and 19) is completed for each contributor. Account branch name Sort code BIC/SWIFT code IBAN number Roll number 10

9 Investment instructions Complete this section for new plans and additional payments to existing plans. If you wish to nominate a discretionary asset manager, please complete section 11. Do you wish to nominate a discretionary asset manager? No Yes (If yes please go to section 11) Do you want your plan assets managed within a Zurich Portfolio? No Yes (If yes please complete the rest of section 9 and then go to section 13) If you have answered No to the questions above, please indicate in the table below the assets (insured funds, mutual funds and deposit accounts) you want us to invest in on your behalf and also complete section 10. ISIN is not required for some types of asset such as deposit accounts. If an ISIN does not apply, please mark the column as n/a. For deposit account investments please provide the term and interest rate for the account. If any of the information is incomplete or unclear, we will not be able to place the trade. For new plans you must put at least 3 into the transaction account. You can find the ISIN for most funds in the Funds charges summary. Each mutual fund you invest in will be subject to a trading charge. Please see the information leaflet for details. We apply minimum investment amounts to each asset. Please see the information leaflet for details. Please complete details of any extra assets on a photocopy of this page and ensure it is returned with the application, if there is not enough space to list your chosen assets. Please give investment amounts to two decimal places. Investments into deposit accounts must be in your chosen base currency. Please see the terms and conditions for details of when we will invest in the assets you have selected. Asset name ISIN Investment (this must be completed for insured funds and mutual funds) Transaction account (for new plans you must put n/a at least 3 into the transaction account) Total 100 11

10 Fund declaration This fund declaration must be signed by each authorised signatory if any mutual fund chosen is classed as a qualified fund, experienced investor fund, professional investor fund or specialist fund. Before signing this fund declaration, you should carefully read the terms set out in the prospectus and/or the offering document of the fund. This will tell you if the mutual fund is classed as a qualified fund, experienced investor fund, professional investor fund or specialist fund. Your adviser will be able to explain why these funds do not fall within the category of retail funds in so far as they are not funds designed for general sale to the public. Before signing this fund declaration, your adviser should explain the operation of the mutual fund including all information about risks, charges, penalties and redemption procedures. Before signing this fund declaration, you should seek financial advice regarding the mutual fund you have chosen as investment in the mutual fund is entirely at your own risk. I/We confirm that I/ we meet the requirements of the mutual fund prospectus and/or the offering document and instruct Zurich to place instructions to buy the mutual funds set out in this application form. I/We confirm that I am/we are signing on behalf of the organisation. If there are more than four authorised signatories, please complete their details on a photocopy of this page and ensure it is returned with the application. First authorised signatory Second authorised signatory Third authorised signatory Fourth authorised signatory 12

11 Discretionary asset manager nomination Complete this discretionary asset manager nomination if you wish to nominate a discretionary asset manager to manage the assets in your plan. Do not complete this section if you are nominating a Zurich Portfolio. The discretionary asset management agreement that Zurich has entered into with the discretionary asset manager is a wide ranging authority which allows the trading of assets and the provision of custody services or the selection of a custodian by the discretionary asset manager. You can only nominate a discretionary asset manager that Zurich has an agreement with. A list of discretionary asset managers you can choose from is available from us or your adviser. Discretionary asset manager details Company name and address Contact name (if applicable) Custodian name and address (if applicable) Your adviser will tell you what charges apply for the discretionary asset manager you have nominated. Your adviser will tell you which discretionary asset manager is able to offer discretionary management services for your investment objectives and risk profile. Investment objectives and attitude to risk Please confirm your investment objective Please confirm your attitude to risk I/We request that Zurich appoint the discretionary asset manager named above to manage the assets in my/our plan in accordance with my/our investment objectives and attitude to risk. I/We consent to the release of all relevant personal information relating to the plan to the discretionary asset manager. I am/we are aware that the assets managed by the discretionary asset manager will be owned by Zurich. I am/we are aware that Zurich has entered into a discretionary asset management agreement with the discretionary asset manager which prohibits the discretionary asset manager from investing in assets that are not permitted by Zurich. I am/we are aware that Zurich may need to terminate the discretionary asset management agreement it has in place with a discretionary asset manager. In the event of termination, the assets in the unit fund will be sold and the proceeds transferred back to Zurich, only then will Zurich control the assets previously managed by the discretionary asset manager. I/We acknowledge that I/we may request Zurich to terminate the nomination for the discretionary asset manager to manage the assets, which, if accepted by Zurich, will take place only when all the assets in the unit fund have been sold and the proceeds transferred back to Zurich. Continued 13

Discretionary asset manager nomination (continued) Before signing this discretionary asset manager nomination, you should be aware that Zurich does not endorse the ability or suitability of any discretionary asset manager that you choose to nominate or any custodian which the discretionary asset manager may select. Before signing this discretionary asset manager nomination, you should be aware that the discretionary asset manager will be responsible for investing in assets in accordance with your investment objectives and attitude to risk. Zurich will not be responsible for the actions or decisions taken by the discretionary asset manager in respect of the assets it chooses to invest in your plan. If there are more than four authorised signatories, please complete their details on a photocopy of this page. Please ensure it is returned with the application. First authorised signatory Second authorised signatory Third authorised signatory Fourth authorised signatory 14

12 Regular withdrawals Complete this section for new plans and additional payments to existing plans if you want to start or change regular withdrawals. Do not complete this section if you are taking withdrawals from a Zurich Portfolio. Instructions given here will replace any existing instructions (additional payments only). The maximum regular withdrawal is 7.5 of the plan value each year. Please refer to the information leaflet for details of the minimum regular withdrawal amount and minimum plan value. The earliest date we can start withdrawals is 30 days from the start date of the plan. If on receipt of this application, the date you have specified has passed, we will start withdrawals from the earliest possible date. Please confirm the amount of your regular withdrawal / $ / * each year (*delete as applicable). Regular withdrawals will be taken equally from all policies. Frequency How often do you want to receive a withdrawal? Every month Every three months Every four months Every six months Every year What date would you like your withdrawals to start? It may take up to four working days for the payment to reach your account. If you don t specify a date, the first withdrawal will be made on the next available withdrawal date after the start date of the plan. This must be at least 30 days after the start date of the plan. For example, if your plan starts on 1 June and you have asked for monthly withdrawals, the first withdrawal will be made on 1 July. If you have asked for withdrawals to be made every six months, the first withdrawal will be made on 1 December and if you have asked for yearly withdrawals, the first withdrawal will be made on the next 1 June. Bank details of account holder of bank/building society Account number account is based in Account branch name Account branch address Sort code IBAN number BIC/SWIFT code Roll number Withdrawals requested in euro or US dollars require a valid IBAN (international bank account number) and a BIC (bank identifier code) / SWIFT code. A confirmation of verification of identity (see section 17 or 18) will need to be completed if the account holder is not the organisation or one of the authorised signatories. 15

You must have selected sterling as your base currency and benefit currency if you choose the Zurich Portfolio option. Your adviser will tell you what charges apply to the assets held within a Zurich Portfolio. 13 Zurich Portfolio option Only complete this section if you want your plan permitted assets to be managed within a Zurich Portfolio. If you complete this section, you must also complete section 15. A) Zurich Portfolio nomination The agreement that Zurich has entered into with Sterling ISA Managers Limited is a wide ranging authority that allows the trading of assets and the provision of custody services or the selection of a custodian. Sterling ISA Managers Limited details Sterling ISA Managers Limited. Registered in England and Wales under company number 02395416. Registered Office: The Grange, Bishops Cleeve, Cheltenham, GL52 8XX. Sterling ISA Managers Limited will arrange for assets to be registered in the name of Sterling ISA Managers (Nominees) Limited. Declaration I/We request that Zurich appoint Sterling ISA Managers Limited to make the assets in my/our plan available to manage within a Zurich Portfolio. I am/we are aware that, where applicable, Zurich will not sell assets in my/our existing plan until Sterling ISA Managers Limited has confirmed they are able to accept the proceeds of my/our plan into the Zurich Portfolio. I am/we are aware that the assets made available within the Zurich Portfolio will be owned by Zurich. I am/we are aware that Zurich has entered into an agreement with Sterling ISA Managers Limited that prohibits investing in assets that are not permitted by Zurich. I am/we are aware that Zurich may need to terminate the agreement it has in place with Sterling ISA Managers Limited and in the event of termination, Zurich will control the assets previously managed within the Zurich Portfolio. This will take place only when all the assets in the Zurich Portfolio have been sold and the proceeds transferred back to Zurich. I/We acknowledge that I/we may request Zurich to terminate the nomination to have assets managed within a Zurich Portfolio, which, if accepted by Zurich, will take place only when all the assets in the Zurich Portfolio have been sold and the proceeds transferred back to Zurich. I/We acknowledge that Zurich does not endorse the ability or suitability of any adviser or investment adviser that I/we choose to appoint to manage assets held in a Zurich Portfolio. If there are more than four applicants, please First applicant Second applicant complete their details on a photocopy of this page. Please ensure it is returned with the application. Day Month Year Day Month Year Third applicant Fourth applicant Day Month Year Day Month Year 16

Zurich Portfolio option (continued) B) Zurich Portfolio disinvestment strategy You must confirm how you want Sterling ISA Managers Limited to disinvest plan assets to cover charges. What assets do you want to disinvest first to cover charges? Least volatile mutual fund Most recently purchased mutual fund Proportionately across all mutual funds If you are investing in specific assets that you want to exclude from the disinvestment strategy please confirm details of the assets below. Asset name ISIN Number The maximum regular withdrawal is 7.5 of the plan value each year. C) Regular withdrawals from a Zurich Portfolio Only complete this section if you want to set up or change regular withdrawals from your plan. Instructions given here will replace any existing instructions (additional payments only). Please confirm the amount of your regular withdrawal each year. Regular withdrawals will be taken equally from all policies. You may have to pay tax if your yearly withdrawals are more than 5 of your total initial payment and any additional payment. Frequency How often do you want to receive a withdrawal? Every month Every three months Every six months Every year What date would you like your withdrawals to start? (This must be at least 30 days after we receive your request) What date would you like your withdrawals to end? (optional) It may take up to four working days from the date we receive the money from Sterling ISA Managers Limited for the payment to reach your account. If you don t specify a date, the first withdrawal will be made on the next available withdrawal date after the start date of the plan. This must be at least 30 days after the start date of the plan. For example, if your plan starts on 1 June and you have asked for monthly withdrawals, the first withdrawal will be made on 1 July. If you have asked for withdrawals to be made every six months, the first withdrawal will be made on 1 December and if you have asked for yearly withdrawals, the first withdrawal will be made on the next 1 June. 17

Zurich Portfolio option (continued) Income payment strategy To take regular withdrawals, please confirm what assets you want Sterling ISA Managers Limited to sell to fund the withdrawals you are requesting. I want to take the withdrawals proportionately across all mutual fund assets held in the Zurich Portfolio. I want to take the withdrawals from the assets specified in the table below If you specify for a withdrawal to be taken in whole or in part from a model portfolio, the amount will be taken proportionately from each asset within it and you do not need to specify each individual asset. Asset name ISIN number Withdrawal to be taken from asset () Withdrawal payment details of account holder of bank/building society Account number account is based in Account branch name Account branch address Sort code Roll number A confirmation of verification of identity (see section 17) will need to be completed if the account holder is not an applicant. 18

A copy of this application and the terms and conditions are available on request. Completion of this application does not guarantee acceptance. For investments made by an attorney, a certified copy of the power of attorney must be provided. Please read the data protection leaflet carefully. If you do not understand any of the information set out in the leaflet, please ask for more information before signing the plan declaration. All parties to the plan should be made aware of how their personal information will be held and used. Please ensure they have read this notice and the data protection leaflet. 14 Plan declaration This plan declaration must be signed by each authorised signatory on behalf of the organisation. Before signing this plan declaration, you should be aware that the terms and conditions together with the plan schedule and any summary of plan changes form the basis of the insurance contract and will govern the terms of the plan. Before signing this plan declaration, you should carefully read the key features document so that you understand what you are buying, and then keep it safe for future reference. Before signing this plan declaration, your adviser should explain the operation of the assets including all information about risks, charges, penalties and redemption procedures. I/We ask Zurich to accept this application and issue the plan, which will be divided into a number of separate and initially identical policies, in accordance with the terms and conditions. Any additional payment is to be added to my/our existing plan as indicated in this application. I/We declare that the organisation is resident and is incorporated in the United Kingdom. I/We declare that I am/we are not resident in, or a citizen of, the United States of America and that the organisation is not incorporated in, or situated in, the United States of America. I/We declare that to the best of my/our knowledge and belief the information given in this application is true and accurate. If the investment is made on behalf of a donor of a power of attorney I confirm that I am acting on behalf of the donor of a power of attorney and for the donor s own benefit, and to the best of my knowledge and belief the power of attorney is still valid and has not been revoked. Data protection For the purposes of data protection, reference to 'Zurich Group' means Zurich Insurance Group Ltd and its subsidiaries. I/We have received a copy of the data protection leaflet Your privacy is important to us. I/We confirm I/we have read the leaflet which explains how Zurich will look after my/our details and I/we consent to: my/our personal data being used in the way described Zurich, its agents and other Zurich Group companies using my/our information for setting up, processing and administering my/our plan Zurich using a reference agency for identity verification and fraud checking purposes. I/We authorise those asked by Zurich to give such information on production of a copy of this consent. Unless you have advised us otherwise, we may share personal data that you provide to companies within the Zurich Group and with other companies that we establish commercial links with so we and they may contact you (by post, email, telephone or other appropriate means) in order to tell you about carefully selected products, services or offers that we/they believe will be of interest to you. By providing us with your details you consent (and we shall communicate such consent) to companies within the Zurich Group and other companies that we establish commercial links with using your data in this way. If you would prefer us not to do so, please tick here You can ask Zurich at any time to stop using your data in this way by writing to Zurich Life Assurance plc, Zurich Centre, PO Box 1076, Bishops Cleeve, Cheltenham, Gloucestershire, GL50 9NR, UK. I/We have received the consent of the life/lives insured to have their information shared, used and disclosed by Zurich and the Zurich Group in order for this application to be processed by Zurich. First authorised signatory Second authorised signatory If there are more than four authorised signatories, please complete their details on a photocopy of this page and ensure it is returned with the application. Third authorised signatory Fourth authorised signatory 19

15 Adviser authority This adviser authority is for this plan only. A separate authority is required in respect of each plan you have with Zurich. Complete this adviser authority if you want to give authority to your adviser to provide information and/ or instructions to Zurich. This section must be completed for every application where the Zurich Portfolio option has been nominated. I/We hereby authorise the adviser firm detailed below to act on my/our behalf in relation to the matters indicated below and to provide information and/or instructions to Zurich. I/We understand that this authority can be withdrawn at any time by written notification to Zurich and that until such notification is received, Zurich is entitled to rely on this authority and act on any information and/or instructions received from the adviser firm as detailed below as if it/they were given directly by me/us. I/We understand that Zurich will not be responsible for the actions or decisions taken by the adviser in connection with my/our plan. By signing this authority I/we authorise Zurich to accept instructions from the adviser firm detailed below relating to any of the following, on the condition that any payments are made to the planholder(s): Start, amend and/or stop regular withdrawals from the plan; Change details of the bank account into which regular withdrawals are paid; One-off withdrawal or full cash-in; and Buy and sell assets. Zurich reserve the right to amend this list in which case Zurich will require a new adviser authority from you. If there are more than four authorised signatories, please complete their details on a photocopy of this page and ensure it is returned with the application. First authorised signatory Second authorised signatory Third authorised signatory Fourth authorised signatory The adviser firm: I/We confirm that I/we will act only in accordance with complete instructions from the planholder(s) of the plan, after ensuring the planholder(s) has/have received the key features document and the terms and conditions and in accordance with the permissions and authority granted by the Financial Services and Markets Act 2000 or any replacement legislation. Adviser firm name Adviser firm address Adviser name Adviser signature (on behalf of the adviser firm) Zurich agency account number 20

To be completed by the adviser The first adviser details captured will be treated as the lead adviser. 16 Adviser details Adviser name Adviser firm Adviser address Financial Services Register Number Email address Mobile telephone number Zurich agency account number Please tick to confirm that the following statement is true: I confirm that all persons involved in transacting this business are authorised or exempt persons as defined in the Financial Services and Markets Act 2000 and are permitted to conduct this type of business. It is an FCA requirement for product providers to report if advice has been given in relation to all plans sold. Please tick if you have not given advice in relation to this application. If you do not tick, you are indicating advice has been given. Can you confirm that there is an insurable interest? Yes No If business/application was sold, solicited, and/or completed outside the United Kingdom please confirm the name of the country. Adviser's signature 21

Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, and attorneys acting under power of attorney and third parties where you have been required to undertake identification). 17 Confirmation of verification of identity certificate corporate Details of customer Full name of company/organisation Type of entity (corporate, trust, club, etc.) Registered number, if any (or appropriate) Relevant company registry or regulated market listing authority Location of business (full operating address) Registered office (in country of incorporation) Please also complete an International Tax Compliance selfcertification for any trustee, third party and attorneys acting under a power of attorney. Directors or equivalent Principal beneficial owners (over 25) You may use this form for all situations where you verify the identity of a non-individual entity (e.g. private and public corporations, local authorities, trusts, clubs, societies, religious groups etc.). Relevant company registry includes Companies House, other registers such as those maintained by charity commissions (or equivalent) or chambers of commerce. Full names of birth Nationality Full names of birth Nationality I/We confirm that: a) the information above was obtained by me/us in relation to the customer; b) the evidence I/we have obtained to verify the identity of the customer: (tick one only) meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG, or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). c) I/we have reviewed the application and declaration and, based on the knowledge gained about the customer, I/we have (tick one only): no reason to believe the International Tax Compliance self-certification needs any follow up action reason to believe the International Tax Compliance self-certification needs follow up action If follow up action is recommended, please explain why: This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: Note this certificate must be signed by an officer of the introducer firm, who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records, to which this certificate relates. Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; Those who have been subject to Simplified Due Diligence under the Money Laundering Regulations; or Those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant please give reasons below: of person completing this certificate Position We cannot accept photocopies of completed certificates. Full name of regulated firm (or sole trader) Financial Services Register Number 22

Please complete the 18 Confirmation of verification of identity certificate certificate and complete To be completed by an FCA Regulated or EU Regulated Introducer separate certificates for all parties to the contract of applicant*/trustee*/third party*/ (e.g. joint applicants, attorney/deputy* (in full) trustees, settlors, Surname deputies, and attorneys of birth acting under power of Forename(s) attorney and third Nationality parties where you have Mr Mrs Miss Ms Dr been required to Other (please give details) undertake identification). Previous address if moved in the last three months Please also complete an International Tax Compliance selfcertification for any trustee, third party and attorneys acting under a power of attorney. Address *Delete as applicable. Beneficial owners must also be identified if different from the applicants. Please tick the standard evidence box if the case is a face to face sale to a UK resident, otherwise the exceeds standards box should be ticked and supporting documentation sent in. Telephone number I/We confirm that: a) the information above was obtained by me/us in relation to the customer; b) the evidence I/we have obtained to verify the identity of the customer (tick one only): meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG, or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). c) I/we have reviewed the application and declaration and, based on the knowledge gained about the customer, I/we have (tick one only): no reason to believe the International Tax Compliance self-certification needs any follow up action reason to believe the International Tax Compliance self-certification needs follow up action If follow up action is recommended, please explain why: Note this certificate must be signed by an officer of the introducer firm, who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records, to which this certificate relates. This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; Those who have been subject to Simplified Due Diligence under the Money Laundering Regulations; or Those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant please give reasons below: Adviser name, address and telephone number Zurich agency account number Financial Services Register Number We cannot accept photocopies of completed certificates. Telephone number of person completing this certificate Job title 23

Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, deputies, and attorneys acting under power of attorney and third parties where you have been required to undertake identification). Confirmation of verification of identity certificate (continued) To be completed by an FCA Regulated or EU Regulated Introducer of applicant*/trustee*/third party*/ attorney/deputy* (in full) Surname of birth Forename(s) Nationality Mr Mrs Miss Ms Dr Other (please give details) Previous address if moved in the last three months Please also complete an International Tax Compliance selfcertification for any trustee, third party and attorneys acting under a power of attorney. Address *Delete as applicable. Beneficial owners must also be identified if different from the applicants. Please tick the standard evidence box if the case is a face to face sale to a UK resident, otherwise the exceeds standards box should be ticked and supporting documentation sent in. Telephone number I/We confirm that: a) the information above was obtained by me/us in relation to the customer; b) the evidence I/we have obtained to verify the identity of the customer (tick one only): meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG, or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). c) I/we have reviewed the application and declaration and, based on the knowledge gained about the customer, I/we have (tick one only): no reason to believe the International Tax Compliance self-certification needs any follow up action reason to believe the International Tax Compliance self-certification needs follow up action If follow up action is recommended, please explain why: Note this certificate must be signed by an officer of the introducer firm, who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records, to which this certificate relates. This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; Those who have been subject to Simplified Due Diligence under the Money Laundering Regulations; or Those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant please give reasons below: Adviser name, address and telephone number Zurich agency account number Financial Services Register Number We cannot accept photocopies of completed certificates. Telephone number of person completing this certificate Job title 24

Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, deputies, and attorneys acting under power of attorney and third parties where you have been required to undertake identification). Confirmation of verification of identity certificate (continued) To be completed by an FCA Regulated or EU Regulated Introducer of applicant*/trustee*/third party*/ attorney/deputy* (in full) Surname of birth Forename(s) Nationality Mr Mrs Miss Ms Dr Other (please give details) Previous address if moved in the last three months Please also complete an International Tax Compliance selfcertification for any trustee, third party and attorneys acting under a power of attorney. Address *Delete as applicable. Beneficial owners must also be identified if different from the applicants. Please tick the standard evidence box if the case is a face to face sale to a UK resident, otherwise the exceeds standards box should be ticked and supporting documentation sent in. Telephone number I/We confirm that: a) the information above was obtained by me/us in relation to the customer; b) the evidence I/we have obtained to verify the identity of the customer (tick one only): meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG, or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). c) I/we have reviewed the application and declaration and, based on the knowledge gained about the customer, I/we have (tick one only): no reason to believe the International Tax Compliance self-certification needs any follow up action reason to believe the International Tax Compliance self-certification needs follow up action If follow up action is recommended, please explain why: Note this certificate must be signed by an officer of the introducer firm, who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records, to which this certificate relates. This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; Those who have been subject to Simplified Due Diligence under the Money Laundering Regulations; or Those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant please give reasons below: Adviser name, address and telephone number Zurich agency account number Financial Services Register Number We cannot accept photocopies of completed certificates. Telephone number of person completing this certificate Job title 25

Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, deputies, and attorneys acting under power of attorney and third parties where you have been required to undertake identification). Confirmation of verification of identity certificate (continued) To be completed by an FCA Regulated or EU Regulated Introducer of applicant*/trustee*/third party*/ attorney/deputy* (in full) Surname of birth Forename(s) Nationality Mr Mrs Miss Ms Dr Other (please give details) Previous address if moved in the last three months Please also complete an International Tax Compliance selfcertification for any trustee, third party and attorneys acting under a power of attorney. Address *Delete as applicable. Beneficial owners must also be identified if different from the applicants. Please tick the standard evidence box if the case is a face to face sale to a UK resident, otherwise the exceeds standards box should be ticked and supporting documentation sent in. Telephone number I/We confirm that: a) the information above was obtained by me/us in relation to the customer; b) the evidence I/we have obtained to verify the identity of the customer (tick one only): meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG, or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). c) I/we have reviewed the application and declaration and, based on the knowledge gained about the customer, I/we have (tick one only): no reason to believe the International Tax Compliance self-certification needs any follow up action reason to believe the International Tax Compliance self-certification needs follow up action If follow up action is recommended, please explain why: Note this certificate must be signed by an officer of the introducer firm, who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records, to which this certificate relates. This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; Those who have been subject to Simplified Due Diligence under the Money Laundering Regulations; or Those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant please give reasons below: Adviser name, address and telephone number Zurich agency account number Financial Services Register Number We cannot accept photocopies of completed certificates. Telephone number of person completing this certificate Job title 26

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Please let us know if you would like a copy of this in large print or braille, or on audiotape or CD. DP127810A52 (03/15) RRD The Zurich International Portfolio Bond is provided by Zurich Life Assurance plc. Zurich Life Assurance plc is authorised and regulated by the Central Bank of Ireland and subject to limited regulation by the Financial Conduct Authority for the conduct of insurance business in the UK. Registered office: Zurich House, Frascati Road, Blackrock, Co Dublin, Ireland. Registered in Ireland under company number 58098. Telephone number 0370 850 6130. We may record or monitor calls to improve our service.