COPIA QNUPS Retirement Plan

COPIA COPIA Advanced COPIA Advanced Plus AP P LI CATI ON FOR M COPIA QNUPS Retirement Plan

2 COPIA QNUPS Retirement Plan COPIA shall be subject to and interpreted in accordance with the Laws of the Island of Guernsey. If there is any conflict or inconsistency between any statements in this form and the Trust Deed, the terms of the Trust Deed will prevail. The COPIA QNUPS Retirement Plan is a Retirement Annuity Trust Scheme (RATS). The Trust Deed is administered by Overseas Trust and Pension Limited (OTAP) to meet the approvals afforded by Section 157A subsection (4) of the Income Tax (Guernsey) Law 1975, as amended. Check list Before sending us this Application Form, please complete the checklist below. Providing complete information is essential for us to proceed with prompt processing of your COPIA Application Form. You have fully completed all relevant sections of the Application Form. Please sign section 8 and if applicable the bank instruction section 9. Your Professional Adviser has completed all relevant sections of the Application Form. Please sign section 7. You have been provided with written information of all fees, expenses and running costs of your plan by your Professional Adviser. You have signed a copy of the COPIA Fee Schedule. The following documents must be included with the Application Form, without this (where applicable) your application will not be processed: Certified copies of suitable client identification. Certified copies of suitable address verification. Any appropriate third party Application Forms (for investment via a Life Company or via an approved Fund Platform). Any appropriate pension transfer documentation including signed discharge form(s). Loan Application Form, if applicable. Benefit Application Form, if applicable. Completed Bank Instruction Letter for lump sum contribution on page 15, if applicable. Overseas Trust & Pension, PO Box 285, Elizabeth House, Les Ruettes Brayes, St Peter Port, Guernsey, GY1 4LX Overseas Trust and Pension Limited is licensed by the Guernsey Financial Services Commission under the Regulation of Fiduciaries, Administration Businesses and Company Directors, etc (Bailiwick of Guernsey) Law, 2000. Overseas Trust and Pension Limited is registered in Guernsey Number: 55506 Investment Notices: Front-end charges may apply. Any mention of equities and bonds should not be taken as a recommendation to invest in them. We advise you to seek professional investment advice before taking any investment decision. Past performance is not a reliable indicator of future results. Investment values and the income from them can go down as well as up and may be affected by changes in rates of exchange. An investor may not receive back the amount initially invested. FX rates shown within your Valuation are as at the date of the transaction. Data Protection Statement: Overseas Trust and Pension Limited is the data controller in relation to any personal data supplied by you in accordance with the Data Protection (Bailiwick of Guernsey) Law, 2001.

3 Section 1 - Personal Details A. Personal details Title (e.g. Mr/Mrs/Miss/Ms/Dr/Other) Forenames Surname Gender Male Female Nationality Previous Name (if applicable) Marital Status Date of Birth (dd mm yy) Place of Birth of residence (for tax purposes) Tax Information Number (please insert your tax reference number for the jurisdiction in which you pay tax) Permanent residential address Correspondence address (if different from residential address) Home Telephone Mobile Telephone Work Telephone Fax E-mail Address B. Passport details Please insert details of all your passports Passport Issuer Passport Issuer Passport Issuer Passport Number Passport Number Passport Number

4 Section 1 - Personal Details continued C. Employment details Are you Employed Self Employed Retired If retired, please state your last employment details in the section below. Occupation (e.g. engineer, banker, etc) Date of commencement of occupation Name of Business Business Address Nature of Business Position Held What share, if any, do you own of this business? % Please indicate your average annual income / / US$ (delete as applicable) D. Reason for starting a COPIA Please state your reasons for establishing an COPIA plan. (e.g. saving for retirement, no current pension, as an additional pension scheme, long term financial planning etc) E. Source of contribution to COPIA Please state the source of the contribution to your COPIA Plan. For example - income from employment, bonus, sale of property or shares, policy pay out, inheritance, family trust. Supporting documents are required. F. Source of overall personal wealth Please state the activities or circumstances which have generated your total net worth and over what period of time. For example - sale of a private company in., proceeds of life savings, employment income, inheritance. Please provide documentary evidence to support your source of wealth statement, please refer to guidance.

5 Section 2 - Product Details A. Retirement Age I wish to take benefit from my COPIA Retirement plan at age: (please insert appropriate age. Max. 75) I wish to take immediate benefits from my COPIA Retirement plan Yes No B. COPIA Investment Options COPIA Investing in a defined range of Kleinwort Benson investment strategies. COPIA ADVANCED Investing in a wide range of funds via one life company bond. COPIA ADVANCED PLUS Investment flexibility. Including but not limited to: deposit/term accounts, discretionary investment management, investment platforms, listed/unlisted equity, investment property, life company bonds. C. COPIA Investment Selection Please tick ONE investment choice COPIA Kleinwort Benson Investment Strategy Please continue with Section 2 before completing sections 3, 6, 7, 8 & 9 COPIA ADVANCED Life Company Bond Underlying investments can be confirmed with the Bond Provider directly. Please continue with Section 2 before completing sections 4, 6, 7, 8 & 9 COPIA ADVANCED PLUS Open Architecture Please continue with Section 2 before completing sections 5, 6, 7, 8 & 9 D. Contribution information Please complete your contribution method and amount of contribution Nature of contribution or transfer Single contribution Life Bond reassignment or in specie transfer Pension transfer (please complete transfer applicaiton) Amount/Value / / US$ / / US$ / / US$ Regular contribution into Kleinwort Benson Investment Strategies for COPIA (please complete additional form) / / US$ M/Q/H/Y Minimum Single Contribution 20,000 Minimum Regular Contribution* 3,000 p.a Minimum Ad Hoc Contribution 1,000 *If you are only making regular contributions the application must be accompanied by a minimum contribution of 1,000. If your tax and/or pension authority has accepted the COPIA QNUPS Retirement Plan as an approved pension plan, then you will need to observe any local contribution limits and levels. This is the responsibility of the Member and advice should be obtained in this regard from your Professional Adviser. Where a foreign exchange rate is required to be applied, the applicable rate will be the rate at the date the transaction took place.

6 Section 2 - Product Details continued E. Pension transfer information - if applicable Approximate amount of total transfer / / US$ (delete as applicable) If you are transferring funds from an existing pension scheme(s), please provide the pension provider(s) details below. If you are making more than one pension transfer, please provide any additional pension provider(s) details on a separate sheet. You will be required to complete closing fund transfer documentation for the transferring pension scheme. Please refer to your Professional Advisor for details. Transfers will be processed once your application for Membership of COPIA QNUPS has been accepted. Pension Provider Contact No. Provider s Address Policy or Ref. Number Type of Scheme (name, description, etc.) Approximate Amount of Transfer Value / / US$ (delete as applicable) F. Nomination of reporting and benefit currency You are required to nominate the currency of your plan on establishment. This nominated currency will be the currency in which you receive your annual valuation of your plan, and the currency in which your lifetime benefits will be paid, when you reach your selected Benefit Age. If your investment currency differs from your plan currency, OTAP will not be responsible for any exchange rate difference that may apply. All plan fees are charged in Sterling or currency equivalent. I wish to establish my plan in: Sterling US Dollars US$ Euro G. Investor risk profile This section must be completed to assist both you and your Professional Adviser in identifying your investor risk profile. I am looking to take a lump sum withdrawal and/or income from my plan: Within the next 3 years Within the next 3 to 7 years Only after 7 years I consider my attitude towards investment risk as: Low Low - Medium Medium - Low Medium Medium - High

7 Section 2 - Product Details continued H. Investment adviser appointment This is the person who is advising/managing the investment inside COPIA. In accordance with the rules of the COPIA Trust Deed, I hereby appoint the following as my Investment Adviser (who may also be my Professional Adviser). Details Name of Adviser Name of Advisory Firm Address of Advisory Firm Telephone Number Email Address Regulator Reference I confirm that any Investment Adviser appointed is authorised by me to advise on and change the funds or investment strategy for this plan in accordance with my agreement with the adviser and their firm. Such investment instructions are to be advised by the Investment Adviser to OTAP. I understand that OTAP reserves the right to refuse the appointment of an Investment Adviser at its absolute discretion. Charges With reference to any Life Company Bond or Investment Fund I confirm that my Investment Adviser and /or my Professional Adviser has notified me of the charges relating to the selected product and the underlying funds and I confirm that I fully understand and accept the charges. Early Surrender Penalties I confirm that with reference to the selected Life Company or Fund (as above) my Investment Adviser and/or my Professional Adviser has informed me of any potential early surrender penalties and I confirm that I have understood the advice provided and that it is not the intention to take benefit levels or encashment from the plan which would incur early surrender penalties rendered by the Life Company or Platform product. I further confirm that if such early surrender penalties are incurred that I am happy for such penalties to be paid out of my COPIA plan. I understand that such penalties may be incurred if I take a loan from my COPIA plan during any early surrender period. I. Loan (if applicable) If you would like to take an immediate loan from your COPIA QNUPS plan, please tick this box. You will need to complete a Loan Application Form, and submit it with this Application Form. Please be aware of any early redemption or early surrender penalty that may apply to your investment, if you make a loan application during any penalty charging period. Your Professional Advisor will guide you in this area.

8 Section 3 COPIA investing in a defined range of Kleinwort Benson investment strategies Entry is 20,000 or currency equivalent. There is no maximum amount that may be contributed. Additional ad hoc contributions will be accepted subject to a minimum of 1,000 or currency equivalent. On receipt of your contribution, it will be paid into your plan account, net of any immediate benefit payment(s). Please indicate below how you would like your contributions to be invested. If you do not indicate how you would like the contributions to be invested then they will remain in your plan bank account until you ask us to arrange for them to be invested. Fund Name Currency Percentage Investment Initial Charges Annual Charges into each fund Initial Maximum Adviser Commission* Management Charge Maximum Trail Commission* Sterling Euro KB Elite Currency Fund % 0.50% 4.50% 0.30% 0.25% US Dollars US$ KB Elite Multi Asset Conservative Fund Sterling % 0.50% 4.50% 1.50% 0.5% KB Elite Multi-Asset Balanced Fund Sterling % 0.50% 4.50% 1.50% 0.75% KB Elite Multi-Asset Growth Fund Sterling % 0.50% 4.50% 1.50% 0.75% KB Elite Fixed Income Fund Sterling % 0.50% 4.50% 1% 0.25% KB Elite International Equity Fund Sterling % 0.50% 4.50% 1.50% 0.25% KB Elite International Bond Fund Sterling % 0.50% 4.50% 1% 0.25% * Please complete the percentage adviser commission required. Maximum as shown. Optional Life Company Bond details: Name of product Name of Life Company Address of Life Company Your underlying Kleinwort Benson fund selection should be confirmed with the Life Company Bond provider on their application form. Important Note: It is the responsibility of your Investment Adviser to provide you with separate brochures, key features documents and application forms for your chosen investments, and to confirm the suitability of the investment products for your particular circumstances. Your Investment Adviser will agree a fee structure with you in relation to any underlying investments that is recommended, and provide relevant fee paperwork to you. You will need to discuss your retirement plan investment objectives and investment strategy with your appointed Investment Adviser.

9 Section 4 COPIA Advanced investing in a wide range of funds via one life company bond Entry is 50,000 or currency equivalent. There is no maximum amount that may be contributed. Additional ad hoc contributions will be accepted subject to a minimum of 1,000 or currency equivalent. Please arrange for the contributions to be invested as follows: Name of product Name of Life Company Address of Life Company Your underlying fund selection should be confirmed with the Life Company Bond provider on their applicaiton form. On receipt of your contribution, it will be paid into your plan account, net of any immediate benefit payment(s). Important Note: It is the responsibility of your Investment Adviser to provide you with separate brochures, key features documents and application forms for your chosen investments, and to confirm the suitability of the investment products for your particular circumstances. Your Investment Adviser will agree a fee structure with you in relation to any underlying investments that is recommended, and provide relevant fee paperwork to you. You will need to discuss your retirement plan investment objectives and investment strategy with your appointed Investment Adviser.

10 Section 5 COPIA Advanced Plus Investment flexibility. Including but not limited to: deposit/term accounts, discretionary investment management, investment platforms, listed/unlisted equity, investment property, life company bonds. Entry is 75,000 or currency equivalent. There is no maximum amount that may be contributed. Additional ad hoc contributions will be accepted subject to a minimum of 1,000 or currency equivalent. Please provide details of investments Bank accounts: Fixed deposit: Life bond/platform: Other:

11 Section 6 - Beneficiaries Letter of Wishes Nomination of your Beneficiaries You can name beneficiaries who you wish to receive benefits from your COPIA plan after your death. The Trustee and Plan Administrator will give due consideration to these wishes. Please ensure when completing this section that your nominations add up to a total of 100%. 1. Title (e.g. Mr/Mrs/Miss/Ms/Dr/Other) Forenames Surname Residential address Home Telephone Mobile Telephone Work Telephone Date of birth (dd mm yy) Beneficiary s relationship to Member Percentage of distribution % Passport Number Passport Issuer 2. Title (e.g. Mr/Mrs/Miss/Ms/Dr/Other) Forenames Surname Residential address Home Telephone Mobile Telephone Work Telephone Date of birth (dd mm yy) Beneficiary s relationship to Member Percentage of distribution % Passport Number Passport Issuer 3. Title (e.g. Mr/Mrs/Miss/Ms/Dr/Other) Forenames Surname Residential address Home Telephone Mobile Telephone Work Telephone Date of birth (dd mm yy) Beneficiary s relationship to Member Percentage of distribution % Passport Number Passport Issuer

12 Section 6 - Beneficiaries continued 4. Title (e.g. Mr/Mrs/Miss/Ms/Dr/Other) Forenames Surname Residential address Home Telephone Mobile Telephone Work Telephone Date of birth (dd mm yy) Beneficiary s relationship to Member Percentage of distribution % For non-guernsey residents: Passport Number Passport Issuer Notes 1. If there is insufficient space on the Application Form to detail all your Named Beneficiaries, please detail additional Named Beneficiaries on a separate page, then sign and attach to this Application Form. 2. You may change your Named Beneficiaries at any time by submitting a written request to the Trustee and Plan Administrator. 3. Any specific instructions should be provided under separate written cover in the form of a Letter of Wishes addressed to the Trustee and Plan Administrator.

13 Section 7 - Appointment of Professional Adviser Professional Adviser Appointment Please enter the details of your Professional Adviser. Please notify the Trustee of any change to your appointed Professional Adviser in writing. Name of Professional Advisory Firm Name of Professional Adviser Full Address for Correspondence Contact Telephone (ies) of operation Contact Fax Email US Director Details (name and address if applicable) FATCA Status (please tick applicable) FFI NFFE Not Known Broker Code (Internal Use Only) Regulator Reference Number Professional Adviser - Fees and Charges Please state the agreed fee payable: Initial Annual Fixed amount or Fixed amount or Percentage (max 5%) % Percentage (max 1%) % Payable from investment provider or COPIA QNUPS* *Please select one option. Kleinwort Benson Investment Strategies - please complete section 3. We may seek to clarify the fees stated. Professional Adviser Declaration (This section is to be completed and signed by your Professional Adviser.) I confirm that I have arranged or provided appropriate financial, pension transfer and tax advice with regards to the suitability of the COPIA Plan, together with the implications of becoming a Member, for the named applicant. Where I am not suitably qualified I have ensured that the applicant has received appropriate qualified advice and confirm the Plan is suitable for the applicant to enter into. If the applicant is transferring funds out of an existing pension scheme into the Plan, I confirm that I have advised him/her on the advantages and disadvantages of such transfer. I confirm that I have carried out the required analysis of the applicant s circumstances, and have satisfied myself that the Plan is both cost effective and appropriate for the applicant. I confirm that I have fully explained the key features, all costs and risks associated with the Plan to the applicant, and the applicant has confirmed his/her full understanding of the implications of entering into the Plan. I have also explained to the applicant (who has confirmed to me that he/she has understood) that any OTAP branded tax information sheets provided to the applicant are not to be relied upon by the applicant in deciding whether to become a Member of the Plan and are of a generic nature only. Signature Name of Professional Adviser Date

14 Section 8 - Declaration Applicant Declaration This section is to be completed and signed by you. I, the undersigned, apply for Membership of the COPIA QNUPS Retirement Plan, a. I agree to be bound by the rules in the Deed establishing the Plan and agree that such rules shall be the basis of the contract between me and Overseas Trust and Pension Limited (OTAP) as the Trustee and Plan Administrator of the COPIA Deed. b. I understand and accept the terms of the COPIA QNUPS Retirement Plan and the benefits provided thereunder. c. I understand and accept that OTAP does not provide investment advice and is not responsible for my Investment Choice. I understand and agree that appropriate professional advice regarding my plan and Investment Choice should be obtained by me from a Professional Adviser ( PA ). I understand that a PA must be qualified to give investment advice where he/she is also the Investment Adviser. OTAP shall not incur liability for anything done, neglected or omitted to be done by, or in reliance upon the advice given by my PA (who may also be my Investment Adviser). d. I understand and accept that (i) OTAP does not provide any ongoing investment advice after the establishment of my membership of the Plan with regards to the Investment Choice and (ii) I am responsible for ensuring ongoing investment advice is obtained by me from my PA. OTAP shall not incur any liability for anything done, or neglected or omitted to be done by, or in reliance upon the advice given by my PA. e. I confirm that I have received full and complete information and appropriate advice in connection with and understand the implications of my membership of the Plan and my Investment Choice. f. I confirm that I am aware that where my Investment Choice is held via a policy issued by a life company policy or via a fund platform, OTAP are bound by the terms and conditions of that policy or platform. I confirm that I am aware that my Investment Choice is to be managed by an Investment Adviser (who may also be my PA) who is to be nominated and appointed by me. I agree that all communications are to be directed through OTAP. g. I confirm that I am solely responsible for managing the nature of the relationship, be it discretionary or advisory, between myself and appointed Investment Adviser (who may also be my PA) and that should this relationship change in any way that I will notify OTAP in writing. h. I understand and agree that OTAP shall not be responsible for any loss or liability whatsoever arising from, or in connection with the appointment of, or anything neglected or omitted to be done by the Investment Adviser (who may also be my PA). I understand and agree that OTAP shall not incur any liability, howsoever arising, in connection with the investment return or performance of the investments linked to my Investment Choice, any life policy, any investment via a fund platform, and/or my membership of the Plan. i. I hereby agree (so as to bind my estate, personal representative and heirs) to indemnify and keep indemnified OTAP, its delegates, successors and assigns (and each former or current director, officer, employee or affiliate of them) from and against any loss or liability arising from or in connection with the appointment of or any act or thing done neglected or omitted to be done by my PA or the Investment Adviser, or in connection with the investment return or performance of the investments linked to my Investment Choice, any life policy and/or my membership of the Plan howsoever arising. j. I confirm that OTAP are not involved in, or responsible for, my tax affairs, or those of any Named Beneficiary, and that I accept that the Named Beneficiaries concerned are responsible for, (and will comply with), their personal tax responsibilities in any jurisdiction. I confirm that I understand that any OTAP branded tax information provided to me is not to be relied upon by me in deciding whether to become a Member of the Plan. k. I confirm that the assets transferred to the Plan do not represent the proceeds of criminal activity and that I will declare the source and origin of any contribution(s) to the Plan to OTAP prior to their receipt. I accept that if no declaration is given by me to OTAP to this effect OTAP will be entitled to decline such contributions being transferred into the Plan. l. I confirm that I have been provided with written information regarding all fees, expenses and running costs of my membership of the Plan and my Investment Choice together with any fees associated with any life policy and/or fund platform associated with my membership of the Plan. All fees and expenses will be due for settlement out of the assets of my fund held within the Plan. m. Where my initial contribution is made from a transfer out of an existing pension scheme, I confirm that I understand and accept that I may be giving up guarantees and/or benefits that have applied to that scheme and which may not be available to me from the Plan. n. I acknowledge that OTAP has the right to change its published Fee Schedules from time to time by giving one month s written notice to me. o. I declare that all information provided by me in this application form is true and complete. Applicant to Sign and Date Signature of Applicant Print Name Date

15 Section 9 Bank Instruction Letter - Lump Sum Contribution COPIA QNUPS Retirement Plan To: The Manager Please complete name and address of Bank From: (Name(s) and address(es) of account holder(s)) Full Name(s) Address Account Number For Lump Sum Contributions to COPIA: Please transfer electronically, with immediate effect The sum of (amount in figures, stating currency) / / US$ (amount in words, stating remittance currency) to the following account (insert receiving bank details) Name of Beneficiary Bank Account Number IBAN Number Sterling Payment (tick if appropriate) Bank: Kleinwort Benson (Channel Islands) Limited, Dorey Court, St Peter Port, Guernsey, GY1 3BG Sort Code: 60-91-61 Swift Code: REARGGSP Account No: 001-014428-01 Account Name: OTAPL RE QNUPS CLIENT A/C Reference: (Membership Number)* US Dollar (tick if appropriate) Bank: Bank of New York, 48 Wall Street, New York Bank Swift Code: IRVTUS3N ABA Code: 021000018 Account Name: OTAPL RE QNUPS CLIENT A/C Account No: 001-014428-02 Reference: (Membership Number)* Euro Payment (tick if appropriate) Bank: Deutsche Bank, Taunusanlage 12 60325 Frankfurt am Main, Germany Account No: 001-014428-03 Account Name: OTAPL RE QNUPS CLIENT A/C Bank Swift Code: DEUTDEFFBL2:50070010 Reference: (Membership Number)* * To be completed by Overseas Trust and Pension Limited Please accept the above instructions: Signature 1 Signature 2 (if applicable) Date Date Please return this completed form to Overseas Trust and Pension Limited together with the completed Application Form. Overseas Trust and Pension Limited will liaise with the appropriate parties to ensure the electronic transfer(s) are set up.

Overseas Trust & Pension PO Box 285, Elizabeth House, Les Ruettes Brayes, St Peter Port, Guernsey, GY1 4LX Telephone: +44 (0) 1481 723030 E-mail: enquiries@trustandpension.com Visit: www.trustandpension.com Overseas Trust and Pension Limited is licensed by the Guernsey Financial Services Commission under the Regulation of Fiduciaries, Administration Businesses and Company Directors, etc (Bailiwick of Guernsey) Law, 2000. Overseas Trust and Pension Limited is registered in Guernsey Number: 55506