Payment instruction form

of 13 Payment instruction form Policyholder What we need before making a payment To take money out of your policy please fill in all of this form, including the declaration, and send it back within 28 days. Please read the notes at the end of the form first as they ll help you fill in the sections below. Policy owner details Please tell us about the policy owner requesting the surrender. Policy owner Home address, including postcode In case we need to contact you Please let us know your phone number and the best time to call. Number Best time to call Checking your identity We may need to carry out a routine electronic third party identity check, which is the quickest way to check your identity. Please tick this box if you don t want us to carry out this check. If we don t use an electronic check, there may be a delay in paying out your money. In some cases the electronic checks may not give sufficient scores and we ll need further evidence to be provided. Full surrender Please fully surrender my policy. We need you to send us the original (or replacement) policy schedule, and any other documents about the ownership of the policy. EDM60812 Members of the Association of British Insurers Aviva Life Services UK Limited. Registered in England No 2403746. 2 Rougier Street, York, YO90 1UU. Authorised and regulated by the Financial Conduct Authority. Firm Reference Number 145452. www.aviva.co.uk

of 13 Policy/Bond] number Partial surrender Important you can only do this if you have a unit-linked policy. Please read the Tax brochure we ve enclosed as well as the Tax implications section of the guidance notes. You can only select this option if you re invested in two or more funds. Please tick one box. I would like to withdraw I would like to withdraw from my policy. % of the policy value. How would you like to take the withdrawal from your policy? Please tick one box. Take the value equally across all individual policies (segments). Take the value by cashing in as many individual policies (segments) as needed, taking the remaining amount equally across the rest of the segments. Take the value by surrendering individual policies (segments) only. Take the value from the following fund or funds only: We need you to send us a photocopy of the policy schedule page signed by the policy owner, and any other documents about the ownership of the policy. Working out your surrender value We ll do this using the bid price on the date we receive everything we need. So, if you re surrendering some or all of your individual policies (segments), the final value of these could be higher or lower than at present. If you re withdrawing a set amount from your policy, the bid price used will affect the number of units we surrender to give you the amount you need. Don t worry, we ll tell you exactly how many units we ve cashed, the date we did this, and bid price we used, when we make your payment. Guarantees Please think carefully before going ahead and consider any guarantees which may apply to your investments in the future. We recommend you talk to a financial adviser about the guarantees that apply to your policy. Deductions Please tick one or both of the boxes below if they apply to your policy. I wish to go ahead with the surrender even though I m aware there is an MVR applying (unit-linked with-profits policies only). I wish to go ahead with the surrender even though I m aware there is an early exit charge applying.

of 13 Bank details Please read the guidance notes for information about the bank account details we can accept. Please fill in your bank details: Account holder name(s) Account number Sort code Roll number (building societies only) of bank/building society Address of bank/building society Accounts outside the UK only If you have any other bank account details that will help us with your payment, please include them on this page. Swift/BIC code IBAN/account number Reference, for instance ABA/BSB We can only pay to an account outside the UK if we have the BIC details. For European bank accounts we ll also need the IBAN details. Cheque payments Only available for UK residents. I would prefer you to make the payment by cheque to my home address. I accept you can only make the cheque payable to the policy owner.

of 13 Other things we need Your payment could be delayed if any of these documents are missing. A known bank account means we already have these details on our files. If the policy is jointly owned, payment should be made into a joint account. If this is not possible, please follow the instructions given for an unknown account (option 3). Please tick the relevant box and enclose any documents we ask for, depending on which payment option you ve chosen. Payment into a bank account I have given details of a known bank account. I have been unable to give a known bank account, but have enclosed the original policy schedule (for a full surrender) or a signed photocopy of the policy schedule page (for a partial surrender). I have been unable to give a known bank account or provide the original policy schedule (for a full surrender) or a signed photocopy of the policy schedule (for a partial surrender) so have signed the attached lost document declaration. I am also enclosing: a certified copy of photo ID, such as a passport or driving licence (we need one for each policyholder). a certified copy of the bank statement for the account the payment should go to (the statement must be less than six months old and show your name, current address and account name). Payment by cheque (UK residents only) I have enclosed the original policy schedule. I am unable to enclose the original policy schedule and have signed the attached lost document declaration. I am also enclosing: a certified copy of photo ID, such as a passport or driving licence (we need one for each policyholder). certified evidence of my address, such as a utility bill or a bank statement. If you have a joint policy we need either a piece of evidence for each policy owner or one piece of evidence showing all policy owners names. Certified copies All copies you send us must be certified by a bank or building society official, solicitor, accountant or financial adviser who has included their full name, position, address and telephone, fax and email details. We can t accept originals, uncertified copies or a copy of a certified copy. Those certifying should write original seen on all documents and on photo evidence they should also confirm it s a true likeness. If it s a poor copy or for any other reason we can t understand what s been written, we may need to ask for further evidence.

of 13 Declaration if you have the original or replacement policy schedule We can only pay the money if all policy owners sign this declaration. If you have the original or replacement policy schedule and any other documents we ve asked you to send, please get all the policy owners to sign this declaration. We don t need you to get any signature witnessed. You re agreeing for Aviva to pay the full or part surrender asked for and confirming you re happy with the payment details. It s important you know we can t reinstate the policy after a full surrender or cancel a part surrender. Where we have said "Aviva", we mean the company that sold the policy or its successor within our Aviva Plc group and where there is more than one claimant each one is making this declaration.

of 13 Your promise if your documents are missing. If you can t send us the original/replacement policy schedule or any other documents about the ownership of the policy, please sign this declaration and make sure someone witnesses each policy owner s signature. Your promise as your documents are missing This will apply if you re unable to send us any documents about the ownership of the policy All policy owners must sign this declaration Documents about the ownership of the policy Usually these will be the original policy schedule but we may also need to see any deeds relating to the policy, such as assignments and trust deeds. I confirm: the documents about the ownership of the policy are missing. the only people who are legally entitled to the money from the policy are those who are signing this form. I ve never been made bankrupt and am not expecting to become bankrupt. in return for payment without the missing documents, I agree to repay all the money and Aviva s costs in retrieving it if it turns out I am not entitled to it. Please be aware Aviva will always try to resist a claim from someone without any right to the money even if they have your documents. We can t pay out any money unless all the policy owners sign the declaration. I agree to Aviva paying the money as described in the form above. The withdrawal/policy can t be reinstated Where we have said "Aviva", we mean the company that sold the policy or its successor within our Aviva Plc group and where there is more than one claimant each one is making this declaration. Witness phone number

of 13 Declaration if you have lost the policy schedule continued

of 13 Form information and guidance notes The notes below will help you fill in the payment instruction form, give details of other documents we may need you to send and give further information about your policy. If you have any questions about the form, you can call me on 0800 068 6800. Tax implications Under present tax laws a withdrawal from your policy may mean you have to pay income tax for any gain. We would recommend you speak to your financial adviser, who will be able to tell you if this applies to you. If you don t have a financial adviser you can visit the IFA Promotions website at unbiased.co.uk, where you ll find details about financial advisers in your area. The UK tax authorities only tax the gain if you live in the UK. If you live outside the UK you may not have to pay any UK income tax, but you may have to pay tax in the country where you live. You should check this with your financial adviser, accountant or the tax authorities. Anti-fraud measures To protect you, and us, from fraud, we have limited the number of ways we ll pay out money and who we ll pay it to. I ve explained these security restrictions below. Please read them carefully as we will only make the payment once we re sure we ve done all we can to look after your money. Policy owner signatures All policy owners must sign and print their name on the declaration. This confirms everyone connected with the policy is happy to have the money paid into that account. Authorised signatures If a company is one of the policy owners please include confirmation of who is authorised to sign on behalf of the company. s If you ve lost the policy schedule please get someone to witness you signing the declaration. The witness must be 18 or over and not related to you. If it s a joint policy, the same person can witness both signatures. The witness is signing to confirm they know you personally and have seen you sign the declaration. Witnesses must include their full details as we may need to contact them as part of our normal security checks. How we ll pay your money We prefer to pay your money directly into a policy owner s known bank account. We pay by direct credit (BACS) because it s the most secure and safest way. What is a known bank account? A policy owner s known bank account is one where we already hold the details on file. For example, it could be the account the initial investment was paid from or where regular payments have been made from or to, for a period of at least six months.

of 13 Can we pay to a different account? Yes, but only if it s not possible to pay into a known account. We won t pay to a third party. Address for sending us your documents Please send this form and any other documents we ve asked for to: Aviva PO Box 520 Norwich NR1 3WG