PENSIONBUILDER CONTINUATION FORM

PENSIONBUILDER CONTINUATION FORM

You should use this form if you have one of the following contracts: Individual Personal Pensionbuilder Company Personal Pensionbuilder Please complete this application form if: 1. You have changed employer 2. You have become self-employed 3. You want to add regular contributions to a rebate only policy 4. You want to recommence regular contributions after a payment holiday Please tick the appropriate box(es). Please write in BLOCK CAPITALS and complete the relevant sections. IMPORTANT: Please ensure the declaration has been signed and dated. WARNING: You must not make false statements when filling in this application; it is a serious offence. The penalties are severe and you could be prosecuted. If you have applied, or are considering applying, to HM Revenue & Customs for Enhanced Protection from any potential lifetime allowance tax charge, such protection will be lost on any payment made to a pension plan on or after 6 April 2006. For further information, please speak to a financial adviser. Is this application being made through your employer? Yes No If Yes, scheme name. A. ELIGIBILITY NOTES (1) Ordinary residence in the UK generally means being resident on a regular basis, i.e. year after year. If you require further information, please speak with your financial adviser. (2) If you tick this box, to be eligible to join the Scottish Widows Personal Pension Scheme, you must have earnings chargeable to UK tax in the tax year you apply. Please note that Scottish Widows can only accept applications from individuals who are ordinarily resident in the United Kingdom, or in a limited number of overseas territories. Unless you are habitually resident in the United Kingdom, or in one of the other territories referred to, we will be unable to accept your application. Please speak with your financial adviser for further details. To be eligible for this plan you must be aged less than 75 and meet one of the following conditions. Please tick whichever applies. I am resident in the UK. (see note 1) OR I do not currently reside in the UK but I am a Crown Servant, or the husband, wife or registered civil partner of a Crown Servant who has general earnings from overseas Crown employment. OR I am not a UK resident, but have earnings which are chargeable to UK income tax. (see note 2) If you have been unable to tick any of the boxes above, you cannot pay contributions to this plan. 1

B. YOUR DETAILS 1. Your Title Mr Mrs Miss Ms Other (please specify) 2. Your Surname 3. Your First name(s) (3) This should be your permanent residential address. We will send all correspondence to this address. Please ensure the postcode is provided. 4. Your address (see note 3) Postcode 5. Country 6. Your Nationality 7. Your phone number (incl code) (4) Sending personal information by email is not secure. Only include your email address if you agree to Scottish Widows sending you emails. (5) A birth certificate should be sent to us with your application. If you have changed your surname, for example, through marriage or a registered civil partnership, a copy of the appropriate certificate should also be sent. 8. Your email address (see note 4) 9. Your date of birth (DD MM YYYY) (see note 5) 10. Are you: Male Female 11. Your marital status Single Married / in a registered civil partnership Separated Divorced / registered civil partnership dissolved Widowed / a surviving registered civil partner (6) If you have income from more than one category, the category that is your main source of income will apply. 12. Employment status (see note 6) Are you: Employed Self employed A pensioner Other If other, please indicate which of the following applies to you. Are you: Caring for one or more children aged under 16 In full-time education Caring for a person aged 16 or over Unemployed Other 13. If you are Employed, please give your employer s name and address (7) Your National Insurance Number can be found on a payslip or P60, or on a tax return. If you have a National Insurance Number, it is essential that you provide it, otherwise, we are unable to accept contributions and cannot process your application. If you cannot find your National Insurance Number please phone the HM Revenue & Customs Enquiry helpline 0845 915 7006. Postcode 14. Your National Insurance Number (see note 7) 15. Your policy number Z03 Please complete sections C or D and sections E, H and I as appropriate, and complete the Direct Debit Mandate. Only complete sections F and G if your employer is paying the cost of life cover. 2

C. COMPLETE THIS PART ONLY IF YOU HAVE BECOME SELF-EMPLOYED 1. When did you become self-employed? 2. What net regular contribution do you wish to contribute? 3. When do you wish to commence regular contributions? 4. If you wish to pay a single contribution please state the amount (a cheque must be sent) Once we have received the above information, we will collect regular contributions from your bank account. D. COMPLETE THIS PART ONLY IF YOU HAVE CHANGED EMPLOYER 1. Your new employer s name 2. Your new employer s address Postcode 3. Your new employer s telephone number (useful if there is a query) 4. Date you entered new employer s service (DD MM YYYY) 5. Will your employer be paying a regular contribution to your personal pension? Yes No 6. Occupation 3

(8) The Money Purchase Annual Allowance (MPAA) is currently 10,000. The MPAA applies to you if you have flexibly accessed your pensions from us or any other provider and have received any of the payments listed below from 6 April 2015 onwards: a payment from a flexible access drawdown fund (also known as a flexi-access drawdown fund); a payment from a capped drawdown fund which would exceed existing capped drawdown limits; a pension encashment (also known as an uncrystallised funds pension lump sum); a payment under a flexible annuity contract; a pension payment from a money purchase scheme which has fewer than 11 other pensioner members; a stand-alone lump sum from a money purchase arrangement where you were entitled to primary protection with a right to take a lump sum of greater than 375,000. The MPAA applies to all contributions you pay (or that are paid on your behalf e.g. employer contributions and death-in-service premiums) each year to all money purchase pension schemes of which you are a member. If the MPAA applies to you and your contributions exceed it, you will be liable to pay a tax charge based on your highest rate of income tax. The MPAA does not apply if you have taken only income from a capped drawdown plan; tax-free cash (pension commencement lump sums) when using your plan to purchase an annuity or drawdown plan; or small pots taken as a cash lump sum. In these circumstances, the higher annual allowance applies to you. (9) We will add basic rate tax relief to the amount you pay. This figure includes any payments made on your behalf by anyone other than your employer. The minimum you can pay is 16 net. (10) This is the actual amount your employer will pay to us. The minimum your employer can pay is 20 gross. (11) Where this application is to pay contributions through your employer s personal pension arrangement the amount and payment date will be set by them. To comply with the late payment rules set by The Pensions Regulator, payments which are made through your employer s bank account must reach Scottish Widows by the 19th of the month following the deduction from salary. For all other cases please choose a payment date up to the 28th of the month. E. PAYMENTS There is no maximum limit on how much can be paid to your plan, although we can only accept contributions from you that are eligible for tax relief. Relief is available on contributions which don t exceed your UK relevant earnings, or 3,600 if higher. The Treasury sets an annual allowance on the amount that can be paid into all your registered pension schemes without incurring a tax charge. Your total contributions are further limited to the Money Purchase Annual Allowance if you have flexibly accessed a pension with us or any other provider. (See note 8) Please speak to your financial adviser if you are unsure about how much you can pay. Have you flexibly accessed any pensions with us or any other provider? (see note 8) Yes No If Yes Date of first payment (DD MM YYYY) Regular payments a) How do you want to pay regular payments? Monthly Yearly b) How much do you want to pay? (see note 9) c) How much is your employer to pay? (see note 10) d) Salary e) When do you want to start paying? (DD MM YYYY) (see note 11) (NET of tax) or % % of salary (NET of tax) (GROSS) or % % of salary (GROSS) Regular payments are usually made by direct debit. To pay by direct debit please complete the attached direct debit instruction. If you wish to pay using another method please contact us for more information. REGULAR CONTRIBUTION DEDUCTION AUTHORISATION If your employer will be deducting your contribution from your salary, you should sign this authorisation and give it to your employer. I authorise the deduction of the appropriate contribution from my salary. Your name (in BLOCK CAPITALS) Your signature Date (DD MM YYYY) 4

F. DEATH BENEFITS ONLY AVAILABLE TO POLICIES STARTED BEFORE 6 APRIL 2001 This is paid if you die before your Personal Pension Age. Fill in this section only if you want this benefit and your employer will be paying the cost of it. Regular payments 1. How much death benefit do you want? The cash value paid on your death is explained in the Member s Booklet you received when you took out this policy. 2. Will your employer pay for this benefit? Yes 3. Do you want the death benefit to be: a) in addition to the cash value of your policy? OR (The cost of this will be in addition to your regular contribution). b) the higher of the cash value of your policy and the amount shown in 1. (The cost of this will be taken from your regular contribution before it is invested). If you have completed this section, please also complete section G. 5

G. MEDICAL QUESTIONS You should complete this section only if you have completed section F. 1. a) Are you already assured with Scottish Widows? Yes No If Yes, please give policy number(s). b) Have you ever withdrawn an application before the company advised you of its decision? Yes No c) Has any application on your life been declined, deferred or offered on non-standard terms? Yes No If Yes, please give details d) Name, address and telephone number of your usual doctor (to whom reference may be made if desired). If your doctor has changed during the past year state also the name, address and telephone number of your previous doctor. Usual doctor Previous doctor Name Address Postcode Telephone number (12) This question must be answered honestly and fully otherwise we may not pay any claims, amend the terms of the life cover or at worst cancel the cover. Tobacco products include cigarettes, cigars, pipes and nicotine replacements. If you have disclosed that you are a non-smoker, you may be asked to take a sample test (e.g saliva or urine test) to confirm you are a non-smoker. (13) This question must be answered honestly and fully otherwise we may not pay any claims, amend the terms of the life cover or at worst cancel the cover. Beer 1 pint = 2.5 units Wine 1 glass (175ml) = 2.5 units 2. a) In the last 12 months, have you smoked cigarettes, a pipe or cigars, or used any other tobacco products or nicotine replacement products? (see note 12) Yes No b) If you smoke cigarettes, how many on average do you smoke per day? c) Do you drink alcohol? (see note 13) Yes No d) Please state your average amount of alcohol units per week 3. a) Have you attended or been advised to attend any hospital or clinic for any advice, treatment, tests or investigations within the last two years or are you currently receiving any medical treatment or attention? Yes No b) Have you had a positive test for HIV or Hepatitis B or C? Yes No If Yes, please give details Spirits 1 standard measures (35ml) = 1.5 units 6

G. MEDICAL QUESTIONS (CONT D) 4. a) Have you ever had any disorder of the heart or circulation, high blood pressure, stroke, diabetes or any form of cancer? Yes No b) Have you ever had any mental or nervous systems disturbance, multiple sclerosis or any respiratory, kidney, urinary, stomach or bowel disorder? Yes No c) Have you any intention of journeying abroad or living outside the UK or have you done so within the last 12 months (excluding holidays or business trips to North America or Europe)? Yes No d) Have you any intention of participating in any hazardous work or leisure activity (eg. flying, climbing, diving, working at heights or motor sports)? Yes No If Yes, please give details 5. a) In the last 12 months have you had any illness or injury which has kept you off work for more than 2 weeks? Yes No b) Do you have any handicap or disability which restricts or is likely to restrict your ability to work? Yes No If Yes, please give details 6. a) What is your height without shoes? b) What is your weight in normal indoor clothing? c) Do you do any physical/manual work? Yes No If Yes, please give details 7

G. MEDICAL QUESTIONS (CONT D) 7. Have any of your family father, mother, brother(s), sister(s) a) died? If so give relationship, cause and age at death. Yes No b) suffered from cancer, diabetes, heart / kidney trouble, stroke, nervous disorder or any hereditary or familial disorder? Yes No If Yes, please give details 8

IMPORTANT NOTES Important Note In accordance with the Association of British Insurers policy on genetics and insurance, you do not need to tell us about any genetic test result you have had if this application for insurance, taken together with any other insurance policies you already have for this type of insurance, totals to: 500,000 or less for life insurance; 300,000 or less for critical illness. Above these limits, you may need to tell us about certain genetic test results when applying for insurance. We will only be interested in genetic test results where the Government s Genetics and Insurance Committee (GAIC) has approved them for insurers to use. If you think this may apply to you, please ask us for details of the current position. These details are also available from the ABI website at www.abi.org.uk/insurance-and-savings/topics-and-issues/genetics However, you must tell us if you either have a family history of, are experiencing symptoms of, or are having treatment for, a medical condition including any genetically inherited condition. If you wish to disclose to us a negative genetic test result, which shows us that you have not inherited a genetic disorder, we will take this into consideration when assessing your application, (providing your clinical geneticist confirms that this test result indicates a reduced risk of developing the inherited disease). Medical Information You must answer all questions honestly and in full. If you don t or you give us incomplete or misleading information, it could mean we will not pay any claim and we may amend the terms of your policy or at worst cancel your cover. We may request a medical examination within 30 days after the commencement date of your plan. This forms part of our quality control procedures and individual cases accepted without medical evidence are selected at random. The medical examination may include cotinine testing for tobacco products. If any of your answers change between submitting your application and the date we have agreed the terms for your cover, you must tell us or we could refuse a claim. Please note, should you die before we receive your signed Customer Signature Form, we will approach your estate for consent to access your medical records. If consent is not granted then Scottish Widows may not pay out on your plan. General Practitioner s Report Declaration and Consent Important Notes We may ask you to contact your doctor if we are waiting for reports which we have asked for. If we ask you to come for a medical examination, we will need to share the application information with another company we have authorised. They will make the arrangements for the examination to take place. We may need to send your application and relevant medical reports to our reassurers for their opinion or agreement of the terms offered. Or, we may need to send them at a later stage for purposes relating to managing the policy or a claim. You can get details of general reassurance principles and details of any company we use to assess your application from our head office. We have a confidentiality policy in place which means we hold your medical information securely and access is limited to authorised individuals who need to see it. You are entitled to ask for a copy of our standard terms and conditions (policy provisions) and a copy of your application form at any time. The Access to Medical Reports Act 1988, The Access to Personal Files and Medical Reports (Northern Ireland) Order 1991 and The Access to Health Records and Reports (Isle of Man) Act 1993. We may need to get medical reports to support your application. Before we can ask any doctor that you have consulted to fill in a report, we need your permission under the appropriate Act detailed above. Your rights under the appropriate Act are as follows. You do not need to give your permission, but if you do not, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance. 9

IMPORTANT NOTES (CONT D) You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to keep the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us. If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date. If you think that any part of the report is not correct or is misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him or her to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report, or any part of it, if he or she feels that it would cause physical or mental harm to you or others. The medical report your doctor fills in asks about the following. Your current health: Any care, medication or treatment you are currently receiving. The results of referrals or tests you are waiting for. Any time off work in the last three years. Your past health: Details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, Consultations with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of: malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually worsening) diseases; musculoskeletal disease or injury, for example arthritis, rheumatism, back problems or any other disorder of the joints or muscles; Anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose contact with reality), stress or fatigue; suicidal thoughts or attempts at suicide; or conditions related to drug or alcohol misuse or smoking or chewing tobacco products. Details of any biopsies, blood tests, electrocardiograms (heart tests), height and weight if measured in the last two years, urinalyses (tests on urine), x-rays or other investigations. Any blood pressure readings in the last three years. Any history of disease among your parents or brothers or sisters that you have told your doctor about. We have asked your doctor not to reveal information about: negative tests for HIV, Hepatitis B or C; any sexually-transmitted diseases unless there could be long-term effects on your health; or predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from. The information you and your doctor provide about your health may result in us: refusing to provide insurance; increasing premiums above standard rates; setting premiums at standard rates; or applying additional exclusions. If you have any questions about your rights under the appropriate Act or questions relating to the process of getting, assessing or storing medical information, please write to: Principal Medical Officer, Scottish Widows Limited, 15 Dalkeith Road, Edinburgh EH16 5BU Do you require to see any medical report on yourself before it is sent to Scottish Widows? Yes No 10

H. NOMINATION FORM Nomination To: Scottish Widows PLEASE USE BLOCK CAPITALS Name Pension Plan Number (for new policies the Scheme Administrator will insert this when allocated) I wish to nominate the person/people listed below to receive any death benefits which become payable under the Pension Plan Number above. I understand that in exercising discretion in applying the benefits the Scheme Administrator will not be bound by this expression of my wishes. Please consider the following people to receive death benefits in the percentages shown. Full name Relationship (if any) Percentage of benefits This form supersedes any earlier form completed in respect of this plan number. If your circumstances change after submitting this form and you would like to change the nominated beneficiaries please send a new form. If you would like further information on placing any death benefit under trust, please tick this box and we will send you a Scottish Widows Pension Trust form. Note: Scottish Widows Pension Trust form has been drafted primarily for use by personal pension and stakeholder pension plan holders who are UK resident. We strongly advise that planholders take legal advice before completing any trust form in respect of their plan, to ensure that their wishes are properly given effect to. This is particularly relevant where the planholder is not domiciled in the UK. Your signature Date (DD MM YYYY) 11

I. DECLARATION IMPORTANT PLEASE COMPLETE SCOTTISH WIDOWS APPROPRIATE PERSONAL PENSION SCHEME (the Scheme) As the administrator of the Scheme, Scottish Widows agrees to run the Scheme according to the Rules. Each policy will consist of one or more Arrangements made for providing benefits under the Rules. I apply to become a member of the Scheme and: a) I agree to be bound by the Declaration which established the Scheme; the Rules of the Scheme; and the Policy Provisions. b) I declare that: i) I am eligible to join the scheme as I meet the specified condition in section A; ii) for the purposes of obtaining tax relief, total contributions paid by me, or by another individual on my behalf, to the Scheme, and any other registered pension schemes of which I am a member, will not in any tax year, exceed the higher of the basic amount (currently 3,600 gross), and 100% of my relevant UK earnings (less basic rate tax). iii) contributions paid by me, or by another individual on my behalf, which are paid net of basic rate tax, will change if the basic rate of tax changes, to maintain the then total contribution to the Scheme. iv) I will inform Scottish Widows if I am no longer entitled to receive tax relief on my contributions to the Scheme. I will do so by the later of: 5 April in the tax year in which I ceased to be entitled to tax relief; and 30 days after the date I ceased to be entitled to tax relief. v) I will inform Scottish Widows within 30 days if: my employment status, or my employer, should change from that indicated in this application, or I stop residing in the United Kingdom. vi) I confirm that I have answered all the questions honestly and fully. c) I agree that payments received will be invested in one Arrangement. d) I agree that a copy of this application can be treated as the original. e) I have received the Important Notes for Applications document. For your own benefit and protection, please read each of the statements in that document before you sign this application. Scottish Widows will rely on them when administering your contract. If you do not understand any point, please let us know. f) Lloyds Banking Group companies may use your information to contact you by mail, telephone, email or text message about products and services that may be of interest to you. If you do not wish to receive this information please tick this box. g) Unless part (h) (iv) applies, I authorise Scottish Widows to deduct from the account detailed in my application, the contributions specified in the application, and any increases to those contributions that I have either agreed to pay, or subsequently agree to pay. h) If I am applying through my employer: i) I authorise them to appoint and/or alter the financial adviser for the policy. ii) For as long as I remain in my employer s service, I authorise Scottish Widows to provide my employer with any information required by them for the administration of this policy, including any information I request via my employer, but excluding: medical information; personal bank details and those for any third party payments; and information regarding any arrangements made by me for the payment of death benefits from the policy. iii) I authorise my employer, its agents and any agent of mine acting in connection with the policy, to pass to Scottish Widows, any information concerning me that Scottish Widows may require to process the application made on my behalf. iv) I authorise my employer to deduct, from my salary, any contributions due by me under the Scheme, and thereafter for them to be sent to Scottish Widows to be applied under the policy, until instructed otherwise. Your signature Date (DD MM YYYY) A copy of the completed application, Scheme Rules and Policy Provision is available from Scottish Widows. 12

J. DECLARATION BY EMPLOYER Declaration by Employer I/We agree, subject to acceptance of the Employee s Application for membership of the Scottish Widows Appropriate Personal Pension Scheme and for the policy or policies to secure benefits thereunder, to pay either the payments (including any automatic increases to regular payments) shown in Sections E & F of the application or, if applicable, the payments (including any automatic increases to regular payments) shown in the Employer s application. Your signature Date (DD MM YYYY) Position of Signatory For and on behalf of the Employer A copy of the completed application, Scheme Rules and Policy Provisions is available from Scottish Widows. K. DECLARATION OF CONTINUED GOOD HEALTH ONLY COMPLETE THIS SECTION IF YOU HAVE COMPLETED SECTIONS F AND G In connection with the application on my life dated Date (DD MM YYYY) I that date, and to the best of my knowledge and belief, the life to be assured, hereby declare that since *1. I have continued in good health and have not had any illness or injury, or sought or received professional advice regarding my health. *2. There has been no change in family history, occupation, prospects of foreign residence, or prospects of engaging in any form of flying or hazardous sport or pursuit. *3. Any subsequent application/proposal on my life made to another office has been dealt with by acceptance at the ordinary rate of premium. * Should any of these statements require modification, the clause in question should be deleted, and full particulars given below. Signature of the life to be assured Date (DD MM YYYY) NOTE: This declaration is valid for 6 weeks from the date of signature shown above. A further declaration will be required if the first premium or a valid Direct Debit Instruction or Standing Order is not received by Scottish Widows within that period. 13

DIRECT DEBIT INSTRUCTION To the Manager Bank/Building Society Address Originator s ID Number 9 0 6 5 7 2 Postcode Please complete parts 1 to 4 and 6 to instruct your bank/building society to make payments directly from your account. When completed please return the form to: Scottish Widows Limited, 15 Dalkeith Road, Edinburgh EH16 5BU. 1. Please write the full postal address of your branch in the box above 2. Name of account holder(s) 3. Account Number 4. Sort Code 5. Payment arrangement reference For Scottish Widows use only. 6. Your instructions to the bank/building society and signature. Please pay Scottish Widows Limited Direct Debits from the account details on this Instruction, subject to the safeguards assured by the Direct Debit Guarantee. Signature(s) Date (DD MM YYYY) Please note that some banks/building societies may refuse to accept instructions to pay direct debts from some types of account. Please detach this guarantee and keep it for your records. THE DIRECT DEBIT GUARANTEE This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits If there are any changes to the amount, date or frequency of your Direct Debit Scottish Widows Limited will notify you 14 working days in advance of your account being debited or as otherwise agreed. If you request Scottish Widows Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request If an error is made in the payment of your Direct Debit, by Scottish Widows Limited or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society If you receive a refund you are not entitled to, you must pay it back when Scottish Widows Limited asks you to You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

Scottish Widows Limited. Registered in England and Wales No. 3196171. Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number 181655. 15800 12/15