pension income plus pension income plus annuity Annuity

No ID or age evidence required pension income plus pension income plus annuity Annuity Application Form For Financial Adviser completion only Adviser Financial Services Register number Adviser email address I confirm that any adviser charge is only for pension advice in connection with the purchase of this annuity Yes Quote Reference A N N

Before you complete this form n Please read the key features document, as it contains important information about your annuity. n Please note that we can t accept the following: n any pension funds with an earmarking order (Pension earmarking is one of the options available on divorce, or the dissolution of a civil partnership.) n any payments from defined benefit schemes using the open market option route (we can only accept these using the transfer route) n any applications from US residents You should complete this form If you wish to use your pension funds in a registered pension scheme to buy a Pension Income Plus annuity with LV=. We can (please tick your required option): (A) accept a full transfer where n you choose to transfer one or more of your pension funds from your current registered pension scheme(s) to the LV Personal Pension Scheme, which is administered by NM Pensions Trustees Ltd n you will then become a member of this scheme n we ll pay you any tax-free cash (where applicable) and a lifetime annuity n we ll combine all your pension transfers into one plan (B) accept an open market option where n you ve taken benefits under the rules of your existing registered pension scheme, but have chosen to buy an annuity from LV= n you ve taken any benefits from your current pension scheme (for example as drawdown pension) n a separate plan will usually be set up for each open market option payment we receive n we won t pay you any tax-free cash from this policy. Instead this will be paid by your existing pension scheme Please tell us the number of pension funds coming to LV= to buy an annuity: n If we can t verify your date of birth electronically and we ask you to send us certified copies of any document to prove your date of birth, these must be signed in ink by someone authorised to do so, for example your Financial Adviser, or a Solicitor and stamped with the company stamp. When you ve completed this application form please send this back to us, via your Financial adviser, to the New Business Department, LV= Retirement Solutions, Keynes House, Tilehouse Street, Hitchin, Herts SG5 2DX. 2

Please complete this application form in black ink and block capitals. Section A Your personal details Part A1 Annuitant s details Title Mr/Mrs/Miss/Ms/Dr/Other First name(s) in full Surname Address Daytime Telephone number (including area code) Email address Date of Birth / / (DD/MM/YYYY) We will confirm your name and age using online information agencies. Where we can t, we ll ask you to provide either your original birth certificate, or a certified copy of your passport or photo-card driving licence. Nationality National Insurance Number Are you male or female? Male Female What is your marital status? Single Married/Civil Partner Widowed Divorced Separated Part A2 Beneficiary s details please complete only if a Beneficiary s pension is required This section is for a continued beneficiary s pension in the event of your death. To nominate beneficiaries for death benefit lump sum payments and those payable under the guarantee or value protection option (if chosen), please see section C on the next page. Beneficiary s Title Mr/Mrs/Miss/Ms/Dr/Other Beneficiary s first name(s) in full Beneficiary s surname Date of Birth / / (DD/MM/YYYY) We will confirm your name and age using online information agencies. Where we can t, we ll ask you to provide either your original birth certificate, or a certified copy of your passport or photo-card driving licence. National Insurance Number Are they male or female? Male Female Please specify their relationship to you? Spouse/Civil Partner Partner Other, please specify 3

Section B. Payment details Please tell us where you want your annuity, and any tax-free cash, to be paid. Please note that we can t make payments by cheque, to bank accounts outside the UK or to UK bank accounts that don t accept Bacs payments. Bank/Building Society name Address Name of account holder(s) Sort code Account number Roll number (building societies only) n Please note your annuity is treated as pension income. We ll deduct income tax under the Pay As You Earn (PAYE) system unless HM Revenue & Customs (HMRC) tell us otherwise. If you have a P45 for the current tax year please send us parts 2 and 3 with this application so we can deduct the correct amount of tax. If you don t have a P45 we ll deduct tax using the emergency code on a month 1 basis until HMRC notify us of your current tax code. Section C. Who would you like us to pay any death benefits to? Please tell us who you would like us to pay any death benefits that may become payable as: n A lump sum or continuing payments under a guarantee period. n A value protection lump sum. Please note that for continuing payments under a guarantee period you should only nominate one person as we cannot pay an income from your annuity to more than one person. We will normally take your wishes into account. But, we will exercise our discretion as to whom we pay the death benefit. If you are buying an annuity by using your open market option, you will need to check that the scheme rules allow us to use our discretion before you complete this nomination. Please speak to your financial adviser if you have any questions on how the rules work. Nomination 1 You must complete this for all cases Full name of nominated beneficiary Address Nomination 2 Only complete this where you want more than one person to receive the lump sum Full name of nominated beneficiary Address If you want to nominate more than two people to receive the lump sum please copy this page and attach the completed copy to this application form. If you wish to change your nomination in the future, please write to us to confirm this. 4

Section D. Lifetime allowance check Please complete this section if you are under age 75 Under legislation introduced from 6 April 2006, we have to know whether this annuity takes you over your personal Lifetime Allowance. For most people, their personal Lifetime Allowance is the same as the Standard Lifetime Allowance ( 1.25 million from tax year 2014/15). This is the equivalent fund value used to buy your pensions and annuities rather than the yearly pension or annuity amount you can receive. If this annuity does take you over this limit you may have to pay an additional tax charge. Are the total value of all your pensions and annuity benefits you ve already taken, including any tax-free cash, when added to the benefits you are taking with LV=, more than the Standard Lifetime Allowance? Yes No If you are unsure how to calculate the value of your benefits, please refer to our help sheet or speak to your financial adviser. Do you have a personal Lifetime Allowance different to the Standard Lifetime Allowance, enhanced protection, fixed protection or a protected early retirement age? Yes No If you ve answered Yes to either of these questions please complete our lifetime allowance assessment form. If you don t know the answers to these questions please speak to your financial adviser. We also have a help sheet to help you work out the value of all your pension and annuity benefits. If you d like a copy, please speak to your financial adviser. Please complete this section if you re over age 75 and are taking a lump sum If you re 75 or over and are taking a lump sum, is the amount that you are taking within 25% of your remaining personal Lifetime Allowance? Yes No Understanding the Lifetime Allowance rules is important because if you provide incorrect or incomplete information you may become liable to a Lifetime Allowance tax charge. If you are unsure how to calculate the value of your benefits, please refer to your financial adviser or your current provider(s). Section E. Details of funds used to buy the annuity Please complete this section for all the pension funds you re using to buy an annuity. If the pension funds are coming from more than three arrangements, please photocopy this page. Please provide full details of your registered pension schemes as this will enable us to get the funds to us as quickly as possible. Source 1 How are the funds arriving/ what is being purchased? (Please tick) Transfer Open market option (OMO) Full name of the current provider Full name of pension scheme Type of scheme, for example Personal Pension Administrator/Insurer Address of transferring scheme Name of contact at transferring scheme Telephone number (including area code) Existing plan number Approximate amount of funds coming to LV= 5

Source 2 How are the funds arriving/ what is being purchased? (Please tick) Transfer OMO Full name of the current provider Full name of pension scheme Type of scheme, for example Personal Pension Administrator/Insurer Address of transferring scheme Name of contact at transferring scheme Telephone number (including area code) Existing plan number Approximate amount of funds coming to LV= Source 3 How are the funds arriving/ what is being purchased? (Please tick) Transfer OMO Full name of the current provider Full name of pension scheme Type of scheme, for example Personal Pension Administrator/Insurer Address of transferring scheme Name of contact at transferring scheme Telephone number (including area code) Existing plan number Approximate amount of funds coming to LV= Does this represent the full value of the existing plan for each source? Yes No If no please provide details Do any of the pension funds relate to Pension Credit Rights arising after divorce under the provisions of the Welfare Reform and Pensions Act 1999? Yes No If yes, is the fund a disqualifying Pension Credit? Yes No Are any of the pension funds subject to an earmarking order? Yes No If you aren t sure, speak to your financial adviser. Please note that we can t accept funds with earmarking orders 6

Please complete the below even if your existing provider is paying tax free cash Please confirm who is to pay any tax free cash (tick one box only) LV=. One or more pension funds are transferred from your existing registered pension scheme(s) to the LV Personal Pension Scheme of which you will become a member (immediate vesting personal pension) or Your pension provider (Open Market Option from a single registered pension scheme) Is the maximum tax-free cash required? Yes No If no, what percentage or value is to be taken? (please specify) (Subject to availability of sufficient funds and applicable maximum limits) Do you want any tax free cash paid, to be paid into the same account as your annuity? Yes No Please note that for open market options any tax-free cash paid by your current provider will be paid into the bank or building society account you ve given us on page 4. If you want them to pay the money into a different account instead please provide details below. Name of Bank/Building Society to which the tax-free cash is to be paid Address Account name (for example Mr Adam Smith) Sort code Account number Roll number (building societies only) Section F. Adviser Charge/Commission Please complete this section for all cases. Is this an advised sale? Yes No If this is an advised sale was the advice independent or restricted If the advice was restricted, was it: Tied Multi-tied Whole of market Please complete this section if you want LV= to pay an adviser charge or commission. An adviser charge is the payment you have agreed to pay your financial adviser for the advice provided to you. We won t calculate any VAT to be included in the adviser charges payable. Please include this in the amount stated if relevant. Adviser charge amount expected or % Commission amount expected or % 7

Section G. Important information General n For transfers, payment of the annuity will only begin when we accept this application form and receive the payments from the schemes or arrangements (the plan(s)) listed in Section E. Where you ve applied for us to receive multiple payments, and we receive these payments at different times, we ll pay the money received into a non-interest bearing holding account. The annuity payments won t begin until we ve received all the relevant payments from your existing registered pension schemes. For Open Market Options (OMO), we ll set up each annuity separately as we receive the payments from the schemes or arrangements (the plan(s)) listed in Section E. n The amount of the annuity we pay you may be different to the quote. We ll confirm this when we accept your application. n The contract will be subject to, and governed by, the laws and jurisdiction of England and Wales. n The annuity cannot be cashed in, surrendered or assigned, except in accordance with the relevant legislation and subject to our agreement. All the information that you provide will be shared with all parties to this application. If you would like a copy of any of the relevant documents referred to below, or a copy of this completed application form, please let us know. Warning: it is a serious offence to make false statements; the penalties are severe and could lead to prosecution. Data Protection We ll keep your information and add it to our customer databases even if your application doesn t go ahead. We may use it to keep our records up to date, for business analysis and market research. We won t include you in direct marketing campaigns and we may pass your details to other carefully selected organisations, but only for the purposes listed here. Subject to payment of a fee, if you d like us to send you a copy of the personal information we hold about you, please write to: CCA Department, LV=, County Gates, Bournemouth BH1 2NF For more information about the LV= group of companies please go to www.lv.com. n If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies to prevent fraud and money laundering. n Further details explaining how the information held by fraud prevention agencies may be used can be obtained by writing to Group Financial Crime, LV=, County Gates, Bournemouth BH1 2NF. LV= may use information given to make searches about you at credit reference agencies and other organisations that hold your information (such as from the electoral roll) to check your age and identity. The credit reference agencies and other organisations may keep records of these searches, even if the application doesn t go ahead. LV= may use scoring methods to check your identity and may ask for supporting documents. LV= may use information provided to process my application and manage my policy. The information may be kept electronically or on paper file for as long as the application is being considered, while the policy is active and for an appropriate length of time after that. I agree that LV= may provide my financial adviser with any information relating to my product(s) with LV=, including personal data. If at anytime I change financial adviser, or want LV= to stop providing information to my financial adviser, I will notify LV= directly of this. 8

Section H. Declarations Declaration by the Annuitant Part H1 declaration to Liverpool Victoria Friendly Society Limited (LV=) n I agree that this application form, together with the quote referenced on the front page of this application, forms the basis of my application. n I ve been advised to read Your guide to how we manage our with-profits fund and ask any questions I may have before signing this declaration. n If I decide to cancel the policy, I will return any money paid to me, within the cancellation period. n I instruct LV= to pay my financial adviser the adviser charges or commission specified in this application form. n I agree that my policy will start when LV= receive my completed application. n I agree that LV= will keep my financial adviser updated throughout the application process and will accept any instructions from my financial adviser to make any changes to this application before my plan starts. I also agree that my financial adviser can instruct LV= to make changes to my plan after it has started. n I agree that if I receive benefits (lump sum and/or income) from LV= to which I m not entitled, I ll pay back any such payments. n I agree that if LV= pays an adviser charge to my financial adviser and I cancel my plan within the cancellation period, LV= won t claim this back from my financial adviser. This means we will only return the amount used to purchase your annuity to your current provider. n I declare that to the best of my knowledge and belief the information contained in this application form and provided in my Quote Request Form is complete and true and I have checked any answers completed on my behalf. n I declare that I haven t knowingly withheld or concealed any information that LV= has asked for and I m aware that if I have then this may result in my income payments being reduced. n I agree that by signing this application form I am entering into a legally binding contract with LV= that can only be cancelled within my cancellation period. By completing the application form I agree to allow LV= to request funds from the ceding scheme without delay. I shall inform LV= of any change to the information contained in this application form or provided in my Annuity Quote Request Form occurring before acceptance of this application form and am aware that failure to do so may result in my income payments being reduced. Part H2 declaration to LV= and the current provider for open market options and transfers n I would like to take benefits from the plan(s) listed in Section E. n I authorise you to release all necessary information to LV= to enable the transfer of funds to LV=. n I authorise and instruct you to transfer the funds from the plan(s) as listed in Section E directly to LV=. n I authorise you to obtain from and release to the financial adviser named in this application any additional information that may be required to enable the transfer of funds. n Until this application form is accepted and complete, LV= s responsibility is limited to the return of the total payment(s) to the current provider. n Where the payment(s) made to LV= represent(s) all of the funds under the plan(s) listed in Section E, then payment made as requested will mean that I shall no longer be entitled to receive pension or other benefits from the plan(s) listed. n Where the payment(s) made to LV= represent(s) part of the funds under the plan(s) listed in Section E, then the current provider will be discharged of all claims and responsibilities only in respect of the part of the plan(s) represented by the payment(s). n I confirm that any adviser charge paid on my behalf by LV= on the initial set up of this annuity: - Is wholly connected to the purchase of this annuity; and - Is appropriate to the advice and service my adviser provided me in relation to this annuity purchase. If this is not the case then some or all of the Adviser Charge and any Pension Commencement Lump Sum may become liable to a tax charge, which I may be responsible for. 9

n Where I ve chosen to take tax free cash, it isn t 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. A significant increase is where: The total tax-free cash you receive in the 12 month period ending on the day the tax-free cash from this plan is paid, exceeds 7,500 (for the tax year 2015/16), and more than 30% of those tax-free cash sums is used to make contributions to one or more registered pension schemes which exceed the expected level of contributions. This includes any contributions you pay directly or indirectly, paid by someone on your behalf such as your employer, or which you may have paid in anticipation of receiving the tax-free cash. n I confirm that: a) The total value of: - the pension income [and tax-free cash] I have already taken (including drawdown income and any income taken before 6 April 2006); - any pension funds transferred overseas, and; - the benefits I am taking now. are below the current standard Lifetime Allowance threshold of 1.25 million from the tax year 2014/15; b) If I have a pension which was in payment as at 5 April 2006 and I have not already taken benefits from any other scheme I will provide the current provider(s) and LV= with details of the level of income currently in payment; or c) I will notify the current providers and LV= if I am, or believe I am above the standard Lifetime Allowance threshold; d) I will advise them if I have a protection in place against the Lifetime Allowance tax charge. I will provide a copy of my HMRC protection certificate if asked to do so. n 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 ve failed to comply with any aspect of this application. n In addition, I promise that I will be responsible for any losses and/or expenses incurred by LV= or the scheme provider, which are the result, and which a reasonable person would consider to be the probable result, of any untrue, misleading or inaccurate information deliberately or carelessly given by me, or on my behalf, either in this form or with respect to benefits from the plan. Part H3 additional declaration to LV= for transfers n I apply to become a member of the LV Personal Pension Scheme and agree to be bound by its trust deed and rules, and the relevant Policy Conditions. n I request LV= to use the transfer payments to provide the benefits set out in the quote referenced on the front page of this application. n I confirm that I ve been provided with an opportunity to select the insurance company from which to buy my annuity, and have chosen to apply for an annuity from LV=. n If an employer is paying contributions to any of the plans as listed in Section E, I authorise you release to that employer any relevant information in connection with the transfer of funds from the relevant plan(s). Part H4 additional declaration to LV= for open market options n I request the trustees/scheme administrator of the plan(s) listed in Section E (the current provider) to buy an annuity from LV=. n I request that the annuity is set up as specified in this application and the quote referenced on the front page of this application and declare that this is allowed within the rules of the current pension scheme or buyout policy. Part H5 additional declaration to the current provider for transfers n Please transfer the fund(s) listed in Section E to LV=. Where you have asked me to give you any original policy document(s) in return for the transfer of funds and I m unable to do so, I promise that I will be responsible for any losses and/or expenses which are the result, and which a reasonable person would consider to be the probable result, of any untrue, misleading or inaccurate information deliberately or carelessly given by me, or on my behalf, either in this form or with respect to benefits from the plan. 10

Part H6 additional declaration to the current provider for open market options n Please pay me any tax-free cash as instructed and pay the balance of funds to LV= to provide me with an annuity on the basis set out in the quote indicated on the front of this application. n If I m buying an annuity for a buy-out policy (deferred annuity) I request the insurer or trustees named in Section E to pass funds to LV=, to buy an annuity using my open market option. Before signing the Declaration below we recommend that you should read the Policy Conditions and Key Features Document. By signing below you are confirming to have read and agree to the statements in the Important Information and Declaration by the Annuitant sections. Print name Signature of Annuitant Date / / (DD/MM/YYYY) What to do next n When you ve completed everything you need to, please send this application to your financial adviser. n Once we ve received your application form, we ll ask your current pension scheme to transfer the money to us. It can take several weeks to receive this money, but we ll regularly keep your financial adviser informed of the progress. If you ve signed the declaration, your application form is now complete. 11

LV.com You can get this and other documents from us in Braille or large print by contacting us. Liverpool Victoria Friendly Society Limited: Keynes House, Tilehouse Street, Hitchin, SG5 2DX. LV= is a registered trade mark of Liverpool Victoria Friendly Society Limited (LVFS) and a trading style of the Liverpool Victoria group of companies. LVFS is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority, register number 110035. NM Pensions Trustees Limited, (registered in England No. 4299742), act as Trustees and Scheme Administrators. Authorised and regulated by the Financial Conduct Authority, register number 463402. Registered address for all companies: County Gates, Bournemouth BH1 2NF. Tel: 01202 292333 21442174 04/15