Your application form Guaranteed Annuity You can use this application if you want to set up a Retirement Advantage Guaranteed Annuity and: You have not applied for fixed, primary or enhanced protection from HMRC; Your total pensions (including those in payment) do not exceed the Standard Lifetime Allowance; Your pension is not subject to a pension sharing court order or earmarking from divorce or dissolution of a civil partnership; The funds are not from any form of defined benefit plan; You have never been declared bankrupt; Power of attorney has not been vested in another party; The annuity is not being purchased from a deceased spouse/civil partner s pension. Please contact us on 0800 032 7690 prior to submitting the application if any of the above apply as there may be additional requirements in order to proceed Checklist Please include the following with the completed application: I confirm that I am a UK resident? Yes Fully completed Common Quotation Form including medical declaration signed and dated by the annuitant (for enhanced cases only) Copy of accepted Key Features Illustration Declarations signed and dated by the annuitant Sale type and intermediary details Identity verification/evidence of age (we will accept certified copies of your driving license or passport). Alternatively a verification form can be found on our website. Please note that if the policy is joint life, we require this for both parties. Quote reference of the annuity illustration that you wish to accept: The quote reference will be shown on your key features illustration (KFI). The KFI has been produced in line with the income option you selected, so it is important you are happy with the options shown in the KFI as the annuity will be set up on the basis set out in this document. Please send completed application forms to: MGM House, Heene Road, Worthing, West Sussex, BN11 3AT.
Section 1 Annuitant s details Second annuitant s details (if applicable) Title Name Title Name Surname Surname Date of birth Date of birth Sex Male Female NI Number Sex Male Female NI Number Marital status Single Married/Civil Partnership Co-habitee Marital status Single Married/Civil Partnership Co-habitee Separated Divorced Widowed Separated Divorced Widowed Name, address and phone Number as per annuitant? If address is different, please complete the details below. Daytime phone number (include area code) Daytime phone number (include area code) Alternative phone number Alternative phone number Address Address Postcode Postcode Email Address Email Address Occupation Occupation Section 2 Bank details (If left uncompleted, delays could be caused in setting up your annuity) Annuitant s bank details (to which annuity income and any tax-free cash lump sum (TFC) should be paid) Name of Account Holder(s) Name of Bank or Building Society Building Society Roll Number (if applicable) Account Number Sort code - - 2
Section 3 Source of pensions funds Please provide details of your current pension fund(s). If you have more than one pension scheme please provide full details of the source for each scheme. Check your chosen key features illustration to ensure that the benefits are as required, and return a copy with this application. This is to ensure that the correct information, pension funds and authority are received promptly, direct from each provider, and also ensure that each pension annuity is set up correctly. Full name of existing provider Full name of existing scheme and existing Pension scheme type Plan number Approximate value to be paid to Retirement Advantage Section 4 Tax Free Cash (TFC) Amount of tax free cash to be paid or already taken (% or ) Name of provider Name of company paying TFC Max % Please tick one Section 5 Data Protection Act 1998 MGM Advantage Life Limited will use the information provided on this form together with any medical and other information about you provided in connection with this application to set up and administer your annuity. We may pass information about you, and any joint applicant, to Retirement Advantage, our third party providers or to any legal or regulatory body. We may use electronic searches, including credit reference agencies that will record any credit searches on your file. This is to help prevent fraud, to check your identity and to prevent money laundering. By completing and submitting this form, and any medical form, you consent to us processing your sensitive data. We may record telephone conversations that you have with us to improve our customer service standards. You have a right under the Data Protection Act 1998 to ask for a copy of your information held by us in our records in return for payment of a small fee, and to ask us to amend any inaccuracies. Please write to: Data Protection Officer, Retirement Advantage, MGM House, Heene Road, Worthing, West Sussex, BN11 3AT. Marketing: Are you happy for Retirement Advantage to contact you by post, phone, or email about other services if we believe they may be of interest to you? Yes No 3
Section 6 Facilitation Agreement When to complete this Section By using this Agreement, you can instruct us to pay remuneration to your Intermediary on your behalf. The remuneration will be an Adviser Charge for advice provided to you in relation to this Plan or an Implementation Fee if your Intermediary has helped you to apply for this Plan without giving any advice and commission is not being paid. In both cases, these charges would come out of the funds we receive. Where the Adviser Charge is for ongoing adviser charges and/ or ad hoc adviser charges, these charges would be deducted from your Plan. This is what we mean by facilitating the payment of these charges from your Plan and our facilitation service is subject to the terms and conditions set out in this Facilitation Agreement. Please note that if, subject to the terms of this Facilitation Agreement, an Adviser Charge or Implementation Fee is stopped, unpaid or is re-credited to your Plan, you may remain financially liable to reimburse your Intermediary for their services provided to you. You should check the terms of your agreement or arrangement with your Intermediary. Please note that the Adviser Charge or Implementation Fee that you are instructing us to pay in accordance with this Facilitation Agreement should only relate to such advice or services provided to you by your Intermediary in connection with your Plan. Retirement Advantage will only accept instructions from you to facilitate the payment of Adviser Charges or an Implementation Fee to your Intermediary by using this Facilitation Agreement and completing the relevant section in your Application Form. The terms and conditions relating to this Facilitation Agreement are set out below and are important. You should take time to read them before you complete and sign this Facilitation Agreement. If you are uncertain about any aspect of this Facilitation Agreement, you should discuss this with your Intermediary. You should retain a copy of this Facilitation Agreement for your records. Adviser Charge and Plan holder s Consent (Page 5) Plan holder s instruction I hereby instruct Retirement Advantage to pay the Adviser Charge or Implementation Fee on the basis set out below and in accordance with the terms and conditions of this Facilitation Agreement. Advised fee* or % of net fund Non-advised Implementation fee* or % of net fund Non-advised Commission* *Note: Subject to maximum levels set by Retirement Advantage. The commission paid for non-advised applications will be based on the commission shown on the initial illustration (%), adjusted to reflect the actual money received from the ceding scheme(s). Section 7 Sale Type and Intermediary Details (to be completed by the intermediary) Intermediary Name (Intermediary responsible for the advice) Financial Adviser Company Name FCA Registration Number (FRN) Contact telephone number Contact email address (Correspondence will be sent to this address) Are you part of/do you subscribe to any network, network support or compliance services? Yes No If so, please provide the name Is this the first time you have submitted business to Retirement Advantage? Yes No If yes, please also complete and attach the Intermediary firm registration form which can be found on our website. www.retirementadvantage.com/adviser Note: Through the submission of business, you will be deemed to have accepted our Terms of Business by your conduct and they will become effective and binding. Terms of Business are on our website www.retirementadvantage.com. 4
Section 8 Declarations If the final value we receive is within 10% of the amount shown on your Key Features Illustration, we will proceed on that basis. If the difference is more than 10%, we will request confirmation that you wish to proceed. Declaration to Retirement Advantage I confirm that the value of all the pensions and tax free cash I have already taken combined with the benefits I am taking now are below the current standard Lifetime Allowance threshold. If you are unsure how to calculate the value of your benefits, please refer to your intermediary or your existing provider(s). I confirm that all of the information provided on the application (including postcode and occupation) are correct I confirm that I have seen the key features document and illustration of my retirement benefits, and I am aware of my cancellation rights. I understand that my pension annuity payments will be paid to the account detailed in this application and that tax will be deducted under PAYE. I authorise Retirement Advantage to seek payment from the pension provider(s) shown in this application, I consent to Retirement Advantage seeking further information from the pension provider(s) and I authorise the giving of the information requested. I understand that purchase of the policy is subject to the consent of the administrator/trustees of the ceding arrangements/scheme. The administrators/trustees consent will be indicated by the completion of the Transfer and Open Market Option form separately to this application. If I have applied for an Immediate Vesting Pension for the purposes of purchasing an annuity, I apply to become a member of the Retirement Advantage Personal Pension Plan for up to six months (if I am not already a member) and agree to be bound by the rules of the plan. Declaration to Existing Pension Provider I authorise you to release all necessary information to Retirement Advantage to enable the transfer of funds to Retirement Advantage. I authorise you to obtain from and release to the intermediary named in this application any additional information that may be required to enable the transfer of funds. Please pay me any TFC if instructed and pay the balance of funds to Retirement Advantage to provide me with an annuity on the basis set out in the illustration indicated in this application. Please transfer the fund(s) listed in Section 3 to Retirement Advantage. Where you have asked me to give you the original policy document(s) in return for the transfer of funds and I am unable to do so, I promise to accept responsibility for any claims, losses and expenses of any nature which you may incur as a result of having made the transfer(s) listed in Section 3. Until this application is accepted and complete, Retirement Advantage s responsibility is limited to the return of the total payment(s) to the existing provider(s). Where the payment(s) made to Retirement Advantage represent(s) all of the funds under the plan(s) listed in Section 3, then payment made as requested will discharge the existing provider(s) of all claims and responsibilities in respect of the plan(s) listed. Where the payment(s) made to Retirement Advantage represent(s) part of the funds under the plan(s) listed in Section 3, then the existing provider(s) will be discharged of all claims and responsibilities only in respect of the part of the plan(s) represented by the payment(s). Declaration to Retirement Advantage and Existing Pension Provider I confirm that the value of all the pensions and TFC I have already taken combined with the benefits I am taking now are below the current standard Lifetime Allowance threshold.* I will be solely responsible for any additional tax charges or any penalties which arise if the information provided in this application is incorrect or if I have failed to comply with any aspect of this application. In addition, I accept responsibility in respect of any claims, losses and expenses that Retirement Advantage and my existing provider may incur as a result of any incorrect information deliberately provided by me in this application or of any failure on my part to comply with any aspect of this application. Where I have chosen to take a TFC, it is not my intention to make, either directly, indirectly or by someone making contributions on my behalf, a significant** increase in my total expected contributions to registered pension schemes. Declaration to this application including an adviser charge (if applicable) I authorise Retirement Advantage to pay any Adviser Charge (where applicable) or Implementation fee on the basis set out in the remuneration section of the facilitation agreement and in accordance with the terms and conditions relating. Note: *If you are unsure how to calculate the value of your lifetime allowance benefits, please refer to your intermediary or your existing provider. **A significant increase is where: The total TFC you receive in the 12 month period ending on the day the TFC from this plan is paid, exceeds 1% of the standard lifetime allowance and more than 30% of the total TFC is used to make contributions (either directly, indirectly or by someone making contributions on your behalf, such as your employer) to one or more registered pension schemes over and above the expected level of contributions. This includes any contributions you may have made in anticipation of receiving the TFC. Please sign to confirm your agreement to this application including adviser charge (if applicable), data protection and declarations Annuitant Signature Date 5
Telephone calls may be recorded for training and quality monitoring purposes. Retirement Advantage is a trading name of MGM Advantage Life Limited. Registered no. 08395855. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Retirement Advantage and the Retirement Advantage logo are trademarks of MGM Advantage Holdings Limited. Registered in England and Wales. Registered office MGM House, Heene Road, Worthing, West Sussex, BN11 3AT. 22-101 07/15