Self Invested Personal Pension (SIPP) Wealth Options Broker Platform Application Product providers for financial advisors
Documentation Checklist Fully completed and signed Applica on Booklet Fully completed and signed New Ireland applica on Form Confirma on of Charges (inc. Pla orm, Pension and Advisors Charge) Cheque payable to New Ireland Assurance or confirma on of direct transfer In order to comply with An -Money Laundering and Terrorist Financing regula ons Wealth Op ons Ltd. and Conexim Advisors Ltd. require the following in order to verify your name and address. Please provide the documenta on as outlined below. Certified Copy of 2 Utility Bills / Bank Statements Not more than 3 months old Certified Copy of Photo ID Valid and in date driving licence or passport Note: These forms are only to be completed for an Investment on the Wealth Op ons Broker Pla orm.
Pensions Personal Pension Plan Wealth Options Self-Invested Personal Pension Initial Commission: % Please complete in BLOCK CAPITALS and tick ( ) where appropriate 1. Personal details Title: Mr Mrs Ms Other First Name: Surname: Address: Date of Birth: Chosen Pension Age: years (must be between 60 75) Sex: Occupation: Male Female Marital Status: Salary: per annum PPS Number: (Personal Public Service No.) Telephone: Email: Maiden name: (if applicable) Please submit evidence of age with this application. 2. Investment details Single Premium Wealth Options SIPP Fund* 100% *Minimum investment in the Wealth Options SIPP Fund is 100,000. 3. Eligibility This form is for the self-employed or people in non-pensionable employment. We are required to ensure you are eligible to start a New Ireland Personal Pension. Please answer the following questions on eligibility. 1. Are you self-employed or a partner personally acting in some trade, profession or occupation? Yes No If NO, are you employed in an occupation which is non-pensionable? Yes No 2. Are you an Irish resident for tax purposes? Yes No Controlling Directors of investment companies are not eligible to effect a Personal Pension. Employment is pensionable if in connection with it, you are a member of any scheme or arrangement from which you expect to receive a retirement benefit which will not have been fully provided out of your own resources. Please give policy numbers of any existing retirement policies with New Ireland. Page 1 of 4
4. Declaration of receipt of disclosure information and policy replacement Please ensure you complete this section before signing this application for assurance. Declaration under Regulation 6(3) of the Life Assurance (Provision of Information) Regulations, 2001. WARNING: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance intermediary. Declaration of Insurer or Intermediary I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the Policy Owner, as stated in Section 1 of the application, has been provided with the information specified in Schedule 1 to those Regulations and that I have advised the client as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction, and of possible financial loss as a result of such replacement. Insurer/ Intermediary Signature: Date: Declaration of Policy Owner I confirm that I have received in writing the information specified in the above declaration. Signature Required Policy Owner Signature: Date: 5. Declarations Investment I request that New Ireland Assurance Company plc links my policy to the Wealth Options SIPP Fund ( the Fund ) to invest in units in the Millennium Unit Trust Series NIA SIPP ( the Unit Trust ). I understand and agree that the assets underlying the Unit Trust must be agreed directly between me and the Unit Trust. I understand and agree that New Ireland Assurance Company plc will not be involved in or take any responsibility for the investment, management or supervision of the assets of the Unit Trust. Signature Required Signature of Applicant: Date: Page 2 of 4
6. Declarations/Data protection consent 1. I declare that all the answers to all the questions in this application are in every respect true and complete and shall be the basis of the proposed contract between me and New Ireland Assurance Company plc. I understand that this contract cannot be surrendered, commuted or assigned except as provided by Sections 784 & 785 of the Taxes Consolidation Act 1997. 2. I understand that the investment fund linked to my contract holds units in the Millennium Unit Trust Series NIA SIPP ( the Unit Trust ) and that the realisable value of those units determines the value of my policy. I understand that the units in the Unit Trust are the sole legal and beneficial property of New Ireland Assurance Company plc. 3. I understand that the value of units in the Unit Trust can fall as well as rise and that for assets denominated in foreign currencies, changes in exchange rates may adversely affect the values of such assets. I understand that any gearing undertaken by the Unit Trust may result in greater volatility than that associated with traditional unit-linked investments. 3. I request that New Ireland link my policy to the Wealth Options SIPP Fund and that I be authorised on behalf of New Ireland, as the unit holders in the Unit Trust, to give instructions regarding the underlying investments of the Unit Trust subject to limitations as laid down from time to time by New Ireland. I understand that this authorisation may be revoked by New Ireland at any time by giving written notice to me. 4. I acknowledge and agree that New Ireland reserves the right to limit the nature and spread of investments underlying the Unit Trust. In addition, I acknowledge and agree that the Unit Trust may enter into transactions on my behalf in non-ready realisable investments. I will inform the trustee of the Unit Trust if I do not wish the underlying assets of the investment fund linked to my policy to be invested in such investments. Where any of the underlying assets of my investment fund are illiquid I understand that New Ireland reserves the right to defer the payment of benefits, either in whole or in part, until such time as the assets can be realised. 5. I acknowledge that my investment will not begin until New Ireland has received and accepted a fully completed application form, any other documentation or information requested and until it has received the investment amount. The Data Controller for the purposes of the Data Protection Acts 1988-2003 is New Ireland Assurance Company plc (New Ireland). The personal data being collected on this form is for the purposes of processing your application and may be disclosed in accordance with and to other parties as identified and consented to in the paragraphs below. Information means any information including medical and non-medical given by me or on my behalf in connection with this application or any further information which may be given at a later stage either in writing, by email, at a meeting or over the telephone. Marketing means direct marketing and cross-selling of the services and/or products provided by New Ireland or arranged by New Ireland with a third party. I understand and consent that New Ireland and its duly authorised agents may: contact me by phone or by letter in relation to the administration (including any contractual review) of the contract; hold and use the Information on computer file, in any other dematerialised form or in written hard copy on its own behalf and may use or pass the Information to third parties for administration, regulatory, customer care and service purposes; disclose and/or transfer my Information to other countries for any of the purposes specified, to persons who have been approved by New Ireland and in a manner compliant with applicable data protection legislation; use my Information to carry out statistical analysis and market research. I agree that New Ireland or a duly authorised agent of New Ireland may contact me in person, by phone, letter, e-mail or other electronic means if it considers that my financial planning arrangements need to be reviewed, my level of cover needs to be revised, and/or to provide me with general information relating to the contract by e-mail or other electronic means with New Ireland at any time. Yes No I agree that the Information may be held and used by New Ireland for Marketing purposes, including Marketing by e-mail or other electronic means. Yes No I understand that I may write to advise New Ireland to cease to hold and use the Information for Marketing purposes at any time. Signature Required Signature of Applicant: Date: Page 3 of 4
7. To be completed by the Insurance Intermediary Name: Agency No.: Branch No.: Broker Consultant s Name: Broker Consultant s No.: Advisor Email: Date Received in Branch: Date Sent to Head Office: Money Laundering Check: Yes No Cert. of Ident. Reqd.: Yes No Application Checked: Yes No Section 30 Receipt: Yes No N/A Factfind: Yes No N/A New Ireland Assurance Company plc., 11-12 Dawson Street, Dublin 2. T: (01) 617 2000 F: (01) 617 2075. E: info@newireland.ie W: www.newireland.ie New Ireland Assurance Company plc is regulated by the Central Bank of Ireland. A member of Bank of Ireland Group. 301379 V3.09.14 Page 4 of 12
Section 8: Managed Portfolios The Model Por olios are risk weighted and designed to match par cular investment objec ves and a tudes to risk. Please select only ONE below. Model Por olio Ultra Defensive Defensive Balanced Equity Focus Targeted Equity Risk Ra ng 2 3 4 5 6 Risk Rated Model Por olio Selec on: Amount: Please ck one of the following op ons: Accumula on Version Distribu on Version Minimum Investment 20,000 Passive Model Portfolios advised by Morningstar Investment Management Europe Ltd. Model Por olio Cau ous Balanced Adventurous Adventurous Plus Income Risk Ra ng 3 4 5 6 4 Risk Rated Model Por olio Selec on: Amount: Minimum Investment 20,000 Please note: Where you have omi ed to choose between the accumula on or distribu on version of a model por olio or fund, the accumula on op on will be chosen by default. Please talk to your Financial Broker about the Por olios above. Please note that Dimensional Fund Advisors and Morningstar Investment Management Europe Limited do not offer model por olios directly to individual investors. Access to these por olios is restricted to a select group of Financial Advisory firms supported on the pla orm. Please see Model Por olio Guides for details of Risk Ra ng. Other Investment Requirements e.g. fund, ETFs, shares etc. Fund / Share Name ISIN/SEDOL Amount Off Platform Investments (Please complete a SIPP Investment Instruction form for any Off Platform Investment) Investment Name Maturity Date Amount 6 Page
Section 9: Self Invested Personal Pension Bank Account (To be completed once SIPP working account is opened) For internal use only Note: These details are required so we can transfer monies to you electronically from your accounts. Please note we cannot transfer monies to third party accounts. Account Name: Name of Bank/Building Society: Address of Bank/Building Society: IBAN No: Swi /BIC: Section 10 - Bene icial Owner Declarations 10 (i) Declara on I declare that the informa on provided by me in this Applica on Form and in this Declara on is correct and I undertake to inform Wealth Op ons without delay and in wri ng should any of the informa on change. 10 (ii) Receipt and Understanding of Terms of Business I have received the Terms rela ng to the Wealth Op ons Broker Pla orm, and have read them carefully. I understand that Wealth Op ons Ltd ( Wealth Op ons ), Conexim Advisors Ltd. ("Conexim"), Pershing Securi es Interna onal Limited ( PSIL ) and I are bound by the Terms if my applica on is accepted. I further note that the Terms may subsequently change as set out in the Terms. 10 (iii) Receipt and Consent of Order Execu on Policy I have received informa on regarding both Conexim and Pershing Security Ltd s ( PSL ) Order Execu on Policy, and by signing this document I consent to having my orders executed as set out in those policies. Details of the Order Execu on Policy are available in the Wealth Op ons Broker Pla orm Terms of Business booklet. 10 (iv) Express Consent to Execu on of an Order outside of a Regulated Market or MTF Where I have requested Conexim to transmit an order for execu on in an instrument admi ed to trading on a Regulated Market ( RM ) or Mul lateral Trading Facility ( MTF ), then I acknowledge that PSL may execute such order outside an RM or MTF in accordance with PSIL s Execu on Policy and I hereby give our express consent for such execu on. 10 (v) Receipt and understanding of Summary Conflicts of Interest Policy I have received and understand the enclosed summary Conflicts of Interest Policies from Wealth Op ons, Conexim and PSIL. Details of the Summary Conflicts of Interest Policy are available in the Wealth Op ons Broker Pla orm Terms of Business booklet. 10 (vi) Fees, Commissions and Charges I have received details of the fees, commissions and charges in rela on to investment in the Wealth Op ons Broker Pla orm and I have agreed to these. I confirm that Conexim has explicit permission to deduct such amounts from your account(s) to sa sfy any indebtedness to Wealth Op ons, Conexim or PSIL. 10 (vii) Taxa on I acknowledge and confirm I understand that there can be no guarantee that the tax treatment or any tax advantage promoted as part of any investment or scheme will remain in existence. I acknowledge and confirm that Wealth Op ons or Conexim will not be responsible for assessing the personal tax implica ons of inves ng in any par cular instrument. I will always take independent professional tax advice before making an investment decision. Conexim will never act as a promoter or tax adviser in rela on to transac ons or schemes designed to enable a person to obtain a tax advantage, as defined in the Finance Act 2010. Should I knowingly receive a tax advantage from any par cular investment or series of investments, I hereby confirm and acknowledge that it is I, my tax advisor, or the promoter of any such scheme who is responsible for disclosing any such tax advantage gained under the mandatory disclosure regime introduced by the Finance Act 2010, or any applicable regime in place at any par cular me, and it is not the responsibility of Wealth Op ons or Conexim to iden fy or disclose any tax advantage gained from any such transac ons. 7 Page
10 (viii) W-8 BEN I have received a copy of the W-8 BEN form and a document designed to assist in its comple on. I will be unable to trade in US Securi es un l a correctly completed W-8 BEN has been provided to Wealth Op ons / Conexim and this has been lodged with the appointed withholding agent. It is beneficial for clients who may be selling US securi es and possibly receiving income in the form of dividends from US securi es to complete this form, as it reduces the tax rate you would ordinarily be charged on such income or sales. This is facilitated by the double taxa on agreement in place between Ireland and the United States. 10 (ix) Contract Notes I understand that within the Risk Rated Model Por olios, I will not receive trade confirma ons for each individual trade entered into, but instead will have the ability to query any transac on in my Wealth Op ons Broker Pla orm online client por olio. Conexim will receive all trade confirma ons on my behalf, and store these in a durable medium. As such, I waive the right to query any par cular detail on each trade confirma on, as provided for in Sec on 21.2 of the Terms of Business. Should you instead wish to receive trade confirma ons for each transac on entered into, please ck here Please note if you hold an account outside of a model por olio, you will receive a contract note automa cally 10 (x) I wish for Wealth Op ons Ltd. /Wealth Op ons Trustees Ltd. / Conexim ( the Providers ) to make investments on the Wealth Op ons Broker Pla orm. I understand that these investment may be made by a Unit Trust and may be subject to the provisions of the Trust Deed as amended. I consent to the Trustees applying for units in the Unit Trust on behalf of my pension/re rement fund. 10 (xi) I hereby consent to the provision of informa on to the Revenue Commissioners if required in rela on to this investment. 10 (xii) I confirm that I wish to make this investment on an execu on only basis having received independent financial advice prior to the making of this investment. I understand that this means that the Providers will provide their services following my request and without having ascertained whether the service is suitable or appropriate for me. I confirm that I have received investment advice from my professional investment advisor or broker before making this investment and confirm that I have provided all the informa on requested by my investment adviser or broker to enable them to confirm that this investment is suitable for me and I confirm that I am instruc ng Conexim following this recommenda on OR I confirm that I have not received any investment advice before making this investment and that this investment decision is en rely at my own ini a ve and risk. I confirm that in either case I have requested the Providers to provide their services to me on an execu on only basis and that I do not wish to provide any financial or other personal informa on to the Providers to enable it to determine whether the service is appropriate for me. Where Conexim may rebalance investments within a model por olio I confirm that such rebalancing is based on the pre-authorised rebalancing instruc on as detailed in the in the Model Por olio Guides, which I have received a copy of, and that such rebalancing does not imply that Conexim is making an assessment of suitability or appropriateness for the purposes of providing services to me, and if any discre on is employed it is only to rebalance the por olio to remain consistent with the characteris cs for each model por olio as specified in the Model Por olio Guides. I understand that values can go down as well as up. I understand that if there is gearing (lending) involved in an investment there may be a higher degree of risk involved in that investment. All fees in the investment have been explained to me and I am sa sfied with the fees. 10 (xiii) If I decide to exercise my cooling off op on on an insured product, my fund will be refunded less the adjustment for any downward movement in the unit price from the date of the investment to policy cancella on date. 10 (xiv) By signing this form I am indemnifying the Providers against any and all costs and claims incurred or suffered arising directly or indirectly out of the signing by the Providers of the Investment applica on and/or making the investment or otherwise in connec on with the investment. 10 (xv) Data Protec on Acts The informa on that you have provided will be treated as confiden al and retained by the Providers for the purposes of financial services or as required by law. You have a right to request a copy of the informa on we hold about you for which we may charge a small fee and to have any inaccuracies in your informa on corrected. Wealth Op ons may use the informa on you have provided for the purposes of providing you with addi onal informa on rela ng to the goods and services of the Providers, it s associated companies and/ or third par es. The Providers may share informa on with its associated and affiliated companies and/ or carefully selected third par es, to enable those associated and affiliated companies and/ or carefully selected third par es, to contact you directly in rela on to their goods and services. If you do not agree to the Providers use of the informa on for such purposes, please ck the box provided. 8 Page
Section 11: Charges Total Annual Charge % * (includes Pla orm, Pension and Advisor Charge - Payable in Advance) *Net Asset Value. Please refer to the charges document for any addi onal charges Section 12 - Consent to Terms Before comple ng and returning this form please ensure that you have read and understood all informa on regarding your Wealth Op ons Broker Pla orm Account and the Services you intend to avail of, including reading and understanding the Model Por olio Guide, Terms of Business, Risk Disclosure No ce, Summary of Conflict of Interest Policy and the Order Execu on Policy. Please sign below to confirm your consent to the terms and condi ons outlined in this document and in the Wealth Op ons Broker Pla orm Terms of Business, and confirm that you are sa sfied that the investment you have requested is suitable for your needs and risk profile, and is consistent with the le er/statement of suitability I have received from my broker/financial advisor. Bondholder Signature: Signature Required Trustee Signature: Intermediary Declara on I declare that I have met the above named applicants and have explained the relevant investments on the Wealth Op ons Broker Pla orm to them and am sa sfied that it is suitable for their needs and risk profile. I can confirm that we have fully complied with An Money Laundering and Terrorist Financing Legisla on. Financial Broker Name: Financial Broker Signature: Financial Broker Firm: Date: 9 Page
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Wealth Options distribute a range of financial services from leading product manufacturers exclusively to regulated intermediaries. Wealth Options do not distribute products directly to the public. Best in Ireland Address: Unit 1C Elm House Millennium Park Naas Co Kildare Tel: Fax: Email: Website: 045 88 22 81 045 88 22 86 info@wealthoptions.ie www.wealthoptions.ie Wealth Options Ltd. & Conexim Advisors Ltd. are regulated by the Central Bank of Ireland Wealth Options Broker Platform is a trading name of Conexim Advisors Ltd. Wealth Options Ltd. Registered in Ireland No: 378600 Conexim Advisors Ltd. Registered in Ireland No: 485863