Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA) Application

Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA) Application Filling in this form This form should be completed by you when you wish to take benefits from your Synergy PRSA. If you want to take benefits from your Synergy PRSA (AVC) policy, you must first provide us with evidence that you are retiring from the occupational pension scheme to which your AVCs relate, such as a letter from your trustee and/or your main scheme provider detailing the benefits you are entitled to and any benefits you have taken. Before completing this form, read the Annuity Key Features document (RIOTAKF1) and/or Synergy approved retirement funds Key Features document (SYARFKF1), Investment Options Guide (SYIO1), Self-Directed Options Guide (SYSDO1) and Illustration, given to you by your financial adviser. RISYPRSA V10 0415 Part 1 - Your details Policy number Is this pension the subject of, or as a result of family law proceedings (for example, Pension Adjustment Order)? If yes, you must enclose a copy of the tice/order and complete Additional information about Pension Adjustment Order form (PAO1). Title First names (in full) Surname Address Email We'll use your email address to set you up for My Standard Life online so that you can check your policy value online at a time that suits you. When your policy is set up, you ll get an email from us with your User ID. Soon after, you ll get your temporary password by post so that you can complete your online registration and view your policy details. Landline phone number Please provide your bank details below. Any benefits requested by you will be lodged to this bank account*. Your International Bank Account Number (IBAN) Your Bank Identifier Code (BIC) Your bank account name Mobile phone number * PRSA income/arf income/ annuity payments/tax free and/or taxed lump sum will be lodged to this account. Please allow at least 5 bank working days for payments to reach your account. Payments must be lodged to your own or jointly owned Irish personal bank account. Payments cannot be made by cheque. Your IBAN and BIC are shown on your bank statement. (The last 14 characters of your Irish bank account's IBAN are your old 6 digit branch sort code (1st digit = 9) and old 8 digit account number). Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA) 01/10

Part 2 Your options Regardless of your selection below, you must complete Part 3. Tick/complete one or more, as appropriate: (i) Take a lump sum^: or (ii) Remain invested in your Synergy PRSA^^ (iii) Purchase a Standard Life retirement annuity (iv) Invest in a Standard Life Synergy approved retirement fund (v) Take an additional lump sum (taxed as earned income) (vi) Send my remaining policy value to (complete Part 12) Annuity provider/qualifying Fund Manager/PRSA provider Address Product name (complete Parts 3, 4, 6, 8, 10-12) (complete Parts 3, 7, 8, 10-12) (complete Parts 3-6, 10-12) (complete Parts 3, 4, 11 and 12) ^ On retirement, up to 25 of your policy value can be taken as a lump sum. See Part 3 for tax limits. ^^ If the Default Investment Strategy applies to your policy, it will not apply once you start taking your benefits. Your policy will remain invested in the funds it was invested in prior to retirement until we are instructed otherwise. Before age 75, you must purchase an ARF or annuity with any remaining policy value. Part 3 Your other pension arrangements By law, at retirement, if the value of all of your pension arrangements is more than the Standard Fund Threshold (2 million), the excess is taxed at 40. There are also lump sum tax limits from all your pension funds: - the first 200,000 will be tax free - the next 300,000 is taxed at 20 - any amount over 500,000 will be treated as income and taxed under the PAYE system Is the current value of all your Irish and overseas pension arrangements more than 2 million? If yes, please give details of all your Irish and overseas pension arrangements, regardless of whether you have taken benefits or not. Insurer/pension provider Policy number Fund value Date you took or propose to take your benefits Lump sum received If you have a personal fund threshold certificate from the Revenue please provide us with a copy. 02/10 Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA)

Part 4 ARF/taxed cash eligibility You need to satisfy the eligibility conditions for investing in an ARF. 1. Do you have an existing ARF, AMRF or Vested PRSA*? 2. If no to question 1, have you a guaranteed pension income for life of 12,700 per annum?** If yes to 1 or 2, please give details and evidence acceptable to Revenue (for example, copy of payment slip, letter from provider) Provider Policy type (Annuity/ARF/AMRF /Vested PRSA) Amount invested Start date Policy number * Vested PRSA is a PRSA where you have taken a cash lump sum and/or income. ** The Revenue accepts your State pension and pension annuities as guaranteed income for life. Income in respect of your spouse/civil partner or dependent is not taken into account. Neither is your salary, State assistance, allowances or benefits, rental income, or maintenance order payments. The Revenue also require us to hold evidence on file. Until you provide satisfactory evidence, your money will not be invested. If you have answered to both questions 1 and 2, you need to (a) Invest in an AMRF which when added to your existing AMRF (if applicable) brings the total AMRF investment to 63,500 (b) Purchase an annuity that, when added to your existing guaranteed pension income (if applicable), brings the total guaranteed pension income to 12,700 per annum or (c) Invest in a combination of an AMRF and an annuity to bring the total investment in an annuity and an AMRF to 63,500. Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA) 03/10

Part 5a ARF investment ARF (minimum 10,000) AMRF (minimum 10,000, maximum 63,500) Part 5b Your ARF investment choice In order to complete this section, refer to the Investment Options guide (SYIO1) and the Self-Directed Options guide (SYSDO1) Indicate how your total premiums as set out in Part 5a are to be allocated Funds and/or Self-Directed Options If you choose to invest in Self-Directed Options, your investment will initially be placed in your Policy Cash Account. You must have enough money in this account to enable us to carry out your instructions and to pay the charges related to the Self-Directed Options that you have selected. If you have different investment choices for your ARF and AMRF premiums, please make a copy of this section and complete it for each policy type. Funds Choose from the following funds Absolute Return Global Bond Strategies Cautious Managed China Equity Corporate Bond Fixed Interest Japanese Equity Global Absolute Managed Return Strategies Global Inflation rth American Equity Linked Bond Global REIT Pacific Basin Equity If you wish to invest in funds, indicate the relevant percentage in the table below. For example, if you indicated above that you wish to invest 10,000 in funds, and you want all of this amount to be invested in the Standard Life Managed Fund, you would insert 100 beside Managed. Euro Global Liquidity European Equity Global Selector Property Global Smaller Companies UK Equity European Ethical Equity European Smaller Companies MyFolio Active India Equity Irish Equity UK Smaller Companies MyFolio Active I MyFolio Active II MyFolio Active III MyFolio Active V MyFolio Active IV MyFolio Market MyFolio Market I MyFolio Market II MyFolio Market III MyFolio Market V MyFolio Market IV 04/10 Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA)

Self-Directed Options Direct property Tick this box if you are purchasing a property. Please provide details of the property you wish to purchase by completing the Property Information Questionnaire (SYPIQ). Execution only stockbroking Tick this box if you are selecting execution only stockbroking. We will pass your details to Stocktrade who will contact you directly. Online dealing If you want to deal or view your Stocktrade account online, please give us your email address. Email address You are only allowed to trade in investments that are permitted by Standard Life. If it comes to our attention that you have bought non-permitted investments, we will instruct Stocktrade to sell those investments. In these circumstances, your policy will be charged the cost of selling those investments. If you are uncertain as to whether a particular investment is permitted, contact your financial adviser or Standard Life. Please note that when choosing this option you must also complete Parts 9a and 9b. Stocktrade will use your email address to set up your online account. Deposits Deposit provider Deposit amount Deposit account term There are minimum investment amounts applied by the Deposit providers. Please see www.standardlife.ie for the minimums that apply. Authorising Standard Life to accept instructions from your financial adviser on your behalf te that we will only accept instructions from authorised persons once we are satisfied that we have verified the identity of the authorised person, and it is the responsibility of the authorised person and/or yourself to verify that your instructions have been carried out properly. I authorise Standard Life to accept instructions from my financial adviser named in Part 10, to buy or sell Funds and Deposits under this policy. This authorisation will apply until Standard Life receives a written instruction from me changing or withdrawing my authorisation. Policyowner signature Date Please speak to your financial adviser before completing this section. Signature Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA) 05/10

Part 6a PRSA/ARF income amount or p.a. (max 5 per annum of policy value before tax) p.a. (max 5 per annum of premium before tax) You must withdraw a certain percentage of the value of your ARF policy on an annual basis. The percentage is: 4, if you're 60 years of age or over for the full tax year, or 5, if you're 70 years of age or over for the full tax year, or 6, if you've combined ARF and vested PRSA assets of 2million or more, and aged 60 or over for the full tax year. If you do not make withdrawals of at least this amount during each year, in December, we will make a withdrawal and lodge it to your bank account. Part 6b - minee Qualifying Fund Manager (QFM) Have you appointed a nominee QFM? If yes, please provide the following details: Name of QFM Address Reference number to be used on correspondence Part 7a Annuity details Purchase price Increase in the annuity The annuity can increase at a fixed rate each year 0 3 Guaranteed period ne 5 years Gross annuity at outset (refer to quote) (minimum 2,500) Other (maximum 5) years Other (maximum 10 years. If more than 5 years, you can t choose a spouse/civil partner s annuity.) The annuity is payable throughout the greater of the lifetime of the Principal Annuitant (you) and the guaranteed period chosen. The guaranteed period applies to the Principal Annuitant s annuity only, not to any Spouse/civil partner s annuity. If Spouse/civil partner s annuity chosen, the maximum guaranteed period is 5 years. Payment to be In arrears In advance If you have chosen a guaranteed period of 5 years of less, this annuity will be with overlap. With overlap: The spouse/civil partner s annuity starts on the Principal Annuitant s death. Part 7b Spouse/civil partner s annuity details (if applicable) Amount 1/2 of Principal annuity 2/3 of Principal annuity Other (please specify) The Spouse/civil partner s annuity will start on the Principal Annuitant s death or at the end of the guaranteed period, whichever is later. Title Surname First names (in full) Date of birth* Personal Public Service number N N N N N N N L (L) Male Female * Proof of your spouse/civil partner s date of birth (for example, a certified copy of passport or driving licence) must be submitted with this application, unless already submitted. 06/10 Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA)

Part 8 PRSA, annuity and ARF income payments Frequency Every month Every 3 months Every 6 months Once a year Your annuity payments will be credited to your bank account on the 1st of the month in which your payment is due. Your 1st payment may be credited on the 15th, depending on when we process your application. Payments must be lodged to your own or jointly owned personal bank account. Payments cannot be made by cheque. The minimum annuity payment each frequency is 65 (treated as income and taxed under the PAYE system). PRSA/ARF first payment date 0 6 (earliest: 1 month after retirement date of PRSA/start date of ARF.) To ensure the correct taxes are deducted from your payments, the Revenue require us to have an up to date Certificate of Tax Credits. Contact the Revenue on (01) 702 3011 or on their PAYE helpline, based on where you live (Standard Life s employer number for PRSAs and ARFs is 9578247P and for Annuities is 0064349F). Dublin region: 1890 333 425 Border Midlands West region: 1890 777 425 South West region: 1890 222 425 East and South East region: 1890 444 425 All PRSA and ARF payments are processed as at 6th of the month or next following working day. Please allow at least five bank working days for payments to reach your account. Emergency taxes will be deducted if we don t receive your Certificate on time.the minimum PRSA/ARF income per annum is 900 (before tax). The minimum annuity payment each frequency is 65 (before tax). If taking an income from your PRSA, an annuity and ARF, we'll assume the same payment instructions apply, unless you tell us otherwise. Separate payments will be made, regardless of payment dates. Please tick to confirm you have contacted the Revenue Only complete Part 9a and Part 9b if you have chosen the Self-Directed option of execution only stockbroking. Part 9a Your occupation and annual income before tax Your occupation Please indicate which income band applies to you Under 20,000 20,000 to 34,999 35,000 to 49,999 50,000 to 74,999 75,000+ Part 9b Proof of your identity and address To comply with anti-money laundering regulations, attach certified copies of one of each of the following: Proof of identity (photo ID) for example Current passport and Proof of address for example Recent bill (electricity, phone or gas) Current EU driving licence Recent statement (bank or credit union), or Recent document from Revenue or Dept of Social Protection showing your name, address and PPSN Current means not expired and recent means issued in the last 6 months. If you don t have a particular document, talk to us or your financial adviser about alternatives. Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA) 07/10

Part 10 Your financial adviser s declaration 1. I confirm that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, my client has been given in writing the information specified in Schedule 1 of those Regulations, and that 2. I have advised my client as to the financial consequences of replacing an existing policy with this policy of cancellation or reduction, and of possible financial losses as a result of such replacement. 3. I have explored the available investment options with my client and taking into account their circumstances, long term needs, age and attitude to risk, I am satisfied that this policy is suitable for them. 4. I confirm that I will retain the appropriate evidence regarding any instructions I give to Standard Life or any third party providers on behalf of my client. 5. If your client has chosen to deal or view their Stocktrade account online, and you want view access, give us your email address. Email address 6. I have verified the identity and address of Policyowner s name to the standards set out in the anti-moneylaundering regulations, which will be forwarded to Standard Life on request*. Financial adviser signature Date Financial adviser s name Stocktrade will use your email address to set up or add this client's policy to your agency's online account. * Enclose verification if Self- Directed Option of executiononly stockbroking chosen. Signature Financial adviser s company name Financial adviser s Standard Life agency code 9/ Commission details Annuity Initial ( of premium) Nil renewal (Max 2.00. If nil, insert 0) ARF/AMRF Please select your Flexible and clear pricing option (tick the appropriate box) For more information on Flexible and clear pricing refer to Products from Standard Life for financial advisers (SYAPS). A B C D E F G H If you are taking FBRC, please choose the payment frequency Monthly Quarterly Half-yearly Yearly Initial ( of premium) FBRC ( of fund) Issue policy to (Max 4.00. If nil, insert 0) (Max 1.00. If nil, insert 0) Financial adviser Client For office use only FPPC 08/10 Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA)

Part 11 Revenue declaration If you have a Personal Fund Threshold Certificate, issued by the Revenue, please enclose a copy with your completed declaration. Where your personal fund threshold includes a defined benefit arrangement, please state the valuation factor used. Information in relation to payment of the State pension from the Department of Social Protection is not required. This declaration should be completed in respect of benefits arising on or after 7 December 2005. 1. Did you become entitled, on or after 07/12/2005, to any pension, lump sum or any other pension related benefit? 2. Prior to, or on, the date of receiving benefits from this pension arrangement, do you expect to become entitled to any pension, lump sum or any other pension related benefit from another pension arrangement? 3. Have you directed, on or after 07/12/2005, or do you intend to direct prior to the date of receiving benefits from this pension arrangement, that a payment or transfer be made to an overseas pension arrangement? If yes to any of the above please provide details below. Scheme name Annuity provider/ Qualifying Fund Manager Policy number Policy type Date of entitlement to benefits Benefit amount Transfer amount or Payment to an overseas arrangement and Contact details for the receiving pension arrangement If a defined contribution arrangement, the value of the fund on the date of benefit entitlement. If a defined benefit arrangement the amount of annual pension, (a) the amount of any lump sum, and (b) the factor used for calculating the capital value of the pension. (c) The amount or market value of any assets transferred by exercise of an ARF option. I declare that to the best of my knowledge and belief, the information in this declaration is correct Policyowner signature Date Signature Retirement instruction for your Synergy Personal Retirement Savings Account (PRSA) 09/10

Part 12 Your authorisation and declaration Please read carefully before signing. 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. 1. I instruct you to retire my Standard Life policy numbers quoted and to distribute the proceeds as detailed in this retirement instruction. 2. I have read the Data Protection tice in my Preliminary Disclosure Certificate and/or my key features document. I agree that my personal information may be used for the purposes described. 3. I consent to Standard Life seeking relevant information relating to my past, present, future employers and pension arrangements from any employers, trustees, administrators or pension providers and I authorise the giving of such information. 4. The information given, whether in my handwriting or not, is true and complete. 5. I agree that a copy of this application can be treated as the original for all purposes. 6. I am beneficially entitled to the assets of the pension fund used to apply for my chosen retirement options and this investment consists only of assets from a Revenue approved pension arrangement, AMRF or ARF. 7. I have received in writing and read the information specified in my financial adviser s declaration (Part 10). 8. If I have applied for an AMRF/ARF, I agree that the contract will be governed by the Policy Schedule, Statement of reasonable projection and Policy Provisions (SYARF60), together with this Application Form and any associated statements or questionnaires submitted in connection with this application. 9. If I have applied for an annuity, I agree that the contract will be governed by the Policy Schedule, Quotation and Policy Provisions (RIOTA60), together with this Application Form and any associated statements or questionnaires submitted in connection with this application. 10. I agree that the contract will be governed by Irish law. Policyowner signature Date Signature If you are receiving advice from a financial adviser, remember that the adviser is acting on your behalf, not only by giving you advice, but also regarding how this form is filled in and sending us this completed instruction/ application. By filling in this form you may be applying to enter into a new contract with Standard Life. If you are, this application will be the basis of this contract if it is accepted by us. A copy of this completed form will be made available on request. Checklist Avoiding delays Your checklist Have you told us what benefits you want to take? Annuity, ARF and/or AMRF? Have you provided details of all your pension arrangements? Have you completed your bank details so that we can lodge payments? If investing in an ARF, have you provided proof of income, and/or details of AMRF and/or annuity? If buying an annuity, have you told us how the annuity is to be set up? Has your financial adviser signed Part 10? Have you signed the relevant parts of the form? (Part 11 and Part 12 are compulsory and Part 5b, if applicable, is optional) (01) 639 7080 www.standardlife.ie customerservice@standardlife.ie Standard Life Assurance Limited is authorised by the Prudential Regulation Authority in the UK and is regulated by the Central Bank of Ireland for conduct of business rules. Standard Life Assurance Limited is registered in Dublin, Ireland (905495) at 90 St Stephen s Green, Dublin 2 and Edinburgh, Scotland (SC286833) at Standard Life House, 30 Lothian Road, Edinburgh EH1 2DH. Calls may be monitored and/or recorded to protect both you and us and help with our training. Call charges will vary. RISYPRSA V10 0415 2015 Standard Life 10/10