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STARTING YOUR DISCOUNTED GIFT TRUST WITH AN Old Mutual InternatIOnal – InternatIOnal POrtfOlIO BOnd – PrIIPsFor use with bare and discretionary versions

We only sell our products through financial advisers as we believe it is important you receive independent financial advice. as it is you who chooses your financial adviser, you need to bear in mind that they are acting on your behalf and not on behalf of Old Mutual International. You are responsible for their actions or omissions.All references to Old Mutual International, we, us and our in this application form mean Old Mutual International Isle of Man Limited.

this application form is for individual applicants resident in the uK only. If you are not applying for an Old Mutual International - International Portfolio Bond with a Discounted Gift Trust, you should use an alternative application form which is available from your financial adviser.IF YOU ARE USING THE BARE TRUST VERSION, WHATEVER MAY HAPPEN IN THE FUTURE, IT WILL NOT BE POSSIBLE TO CHANGE THE BENEFICIARIES.Before completing the application form, please make sure you receive and read the relevant product literature:• Details of your Old Mutual International - International Portfolio Bond – Redemption PRIIPs (ref IPBRv3) or Details of your Old Mutual International -

International Portfolio Bond – Life PRIIPs (ref IPBv3) Policy Terms• Key Features of your International Portfolio Bond – Life PRIIPs or International Portfolio Bond – Redemption PRIIPs• Unlocking the secrets of intelligent investing product brochure• Explaining your Portfolio Bond fees and charges• The International Portfolio Bond – Redemption PRIIPs at a glance or The International Portfolio Bond – Life PRIIPs at a glance Your financial adviser will be able to provide you with the relevant product literature.For further information on applying for a discounted gift trust with an Old Mutual International - International Portfolio Bond please refer to the guidance notes for Starting your discounted gift trust with an Old Mutual International - International Portfolio Bond - for use with bare and discretionary versions (referred to as the guidance notes). If the guidance notes are not attached please ask your financial adviser to provide you with a copy. For ease of reference we have used an arrow uto highlight certain facts and sometimes to let you know that you can find further information and explanations in the guidance notes.

Old Mutual International account number

Name of financial adviser

Company name Address

Telephone number

Fax number

E-mail address

Old Mutual International only accepts business introduced by companies which have Terms of Business with us.

Applicant 1

Applicant 2

financial adviser details

Customer Id number(s)If known please enter the Customer ID number(s)

You have the right to change your mind and cancel your application by giving written notice. Such notice must be sent by you direct to, and received by, Old Mutual International within 30 days from the date your Schedule is received in the post by you. If you decide to cancel, we will give you your money back. However, if the value of your investment has fallen in the meantime, you may not get back the full amount you paid in. Any Old Mutual International charges will be refunded in full. If, at your request, we have facilitated an initial fee for advice given to you by your financial adviser and you decide to cancel your contract we cannot reclaim or refund the fee. The fee agreement is between you and your financial adviser, not Old Mutual International, and it is up to you to reclaim the fee.

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this document was last updated in May 2018. Please confirm with your financial adviser that this is the most up-to-date document for your product or servicing needs.

IMPOrtant InfOrMatIOn fOr YOu – tHe aPPlICant

CanCellatIOn rIGHtS

Under Automatic Exchange of Information (AEOI) regulations Old Mutual International is required to obtain information about an applicant’s tax status. To enable us to comply with these regulations, when submitting this application form you must also submit the ‘Taxation information and self-certification – for entity investors’ form. Completion and submission of a self-certification is mandatory and failure to provide one could result in yourPortfolio being reported under AEOI by default. If any of the information contained in the self-certification changes please advise Old Mutual International promptly so we can determine if a new self-certification is required.

taXatIOn InfOrMatIOn

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In this section, please give details of all individual applicants. Applicants must be at least 18 years old and the maximum age is 89.

Full forename(s)

Surname

Title (3)

Other

Date of birth D D M M Y Y Y Y

Sex (3) Male Female

Occupation(If you have retired or do not have an occupation, please include your previous occupation)

Nationality

Dual nationality(if applicable)

Passport number/national identity card number

Country of residence

Mr Mrs Miss

Other

D D M M Y Y Y Y

Male Female

Mr Mrs Miss

Previous name or aliasu�Please refer to section

B of the guidance notes

Please indicate which type of bond you are applying for: (3)

u Please refer to section a of the guidance notes which explain the difference between the two types of bond.

tHe tYPe Of BOnd CannOt Be CHanGed after It HaS Been Set uP.life assurance (This is called the International Portfolio Bond – Life PRIIPs.)

Capital redemption (This is called the International Portfolio Bond – Redemption PRIIPs.)

I wish my policy to be valued in (3)

If no currency is entered, your policy currency will be pound sterling (£). tHe POlICY CurrenCY CannOt Be CHanGed after tHe POlICY IS Set uP.

u If you are paying your premium in a different currency to your chosen policy currency and for further information on allowable currencies, please refer to sections a and e of the guidance notes.

£ US$ €Other (state currency)

POlICY CurrenCY

a tYPe Of aPPlICatIOn

B detaIlS Of all IndIVIdual aPPlICantS

aPPlICant 1 aPPlICant 2 (If anY)

To complete this form:• use CAPITAL LETTERS only• use blue or black ink• specify choices as appropriate• complete all relevant sections; • do not use correction fluid; any amendments should be crossed out and initialled by all applicants.

Please note that we must receive your application form by post or courier, we are unable to accept faxed or e-mailed versions and the applications received in this way will not be processed. Please ensure that you complete all relevant sections. We will contact you regarding any missing information which will need to be provided to us in writing, and this may delay your application.

COMPletInG tHe fOrM

Residential address(Please note we do not accept c/o and PO Box addresses)

Postcode Postcode

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If the applicant(s), or any other party connected to this application, either now or in the past/future, could be classed as a politically exposed person, or connected with a politically exposed person, please provide details. u for examples of what a politically exposed person is please refer to section B of the guidance notes

all aPPlICantS MuSt COMPlete and SIGn tHe deClaratIOn In SeCtIOn K.addItIOnal dOCuMentS are needed tO eVIdenCe YOur IdentItY – PleaSe refer tO SeCtIOn B Of tHe GuIdanCe nOteS fOr furtHer detaIlS.

Address of employer or your own company

Name of employer or your own company

Website address of employer or your own company (if any)

Country

Occupation

Last year’s gross salary/ income amount

tHIS SeCtIOn MuSt Be COMPleted In all InStanCeS.Please give details of your employer or your own company if self-employed.If you have retired or are not currently employed please include details of your previous employer or your own company. If you have never been employed, please state N/A. Please also enter your final year’s salary/income and bonus if any.

Postcode Postcode

Last year’s bonus amount (if applicable)

Currency (3) £ US$ €

Other(state currency)

£ US$ €


Currency (3)

Employment status (3)

£ US$ €


£ US$ €


If you receive income from another source eg dividends, interest; please provide details here

Employed EmployedSelf Employed Self Employed

Retired RetiredNot employed Not employed

B detaIlS Of all IndIVIdual aPPlICantS (COntInued)

eMPlOYMent detaIlS

POlItICallY eXPOSed PerSOn

aPPlICant 1 aPPlICant 2 (IF ANY)

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this section should only be completed if you have selected the life assurance option, ie the International Portfolio Bond – life PrIIPs, in section a. We recommend that you select a minimum of two lives assured, who are younger than the settlor and in good health. Please note that neither the applicant nor the applicant’s spouse or civil partner (as defined by the UK Civil Partnership Act 2004) should be included as lives assured.

The maximum age for a life assured is 89.

The applicants named in section B (referred to in the trust deed as the ‘settlors’) or their spouses/civil partners (as defined by the Civil Partnership Act 2004) may NOT be included as lives assured because under the Finance Act 1986, Paragraph 7, Schedule 20, a gift with reservation may consequently arise.

u�for more information on assigning the bond into a discounted gift trust please refer to the important information section of the guidance notes. Section C of the guidance notes also has more details on the life/lives assured.

uIf there are any further lives assured, please photocopy this page, attach the details with this application form and tick here (3)

uIf additional pages are added, each separate page must be initialled by all applicants.

Full forename(s)

Surname

Title (3)

Other


Sex (3) Male Female

Mr Mrs Miss

Other

D D M M Y Y Y Y

Male Female

Mr Mrs Miss

Nationality




Postcode Postcode

fIrSt lIfe aSSured (IF ANY) SeCOnd addItIOnal lIfe aSSured (IF ANY)

C detaIlS Of tHe lIfe/lIVeS aSSured

tHIrd addItIOnal lIfe aSSured (IF ANY) fOurtH addItIOnal lIfe aSSured (IF ANY)

Full forename(s)

Surname

Title (3)

Other


Sex (3) Male Female

Mr Mrs Miss

Other

D D M M Y Y Y Y

Male Female

Mr Mrs Miss

Nationality




Postcode Postcode

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tHIS SeCtIOn MuSt Be COMPleted In all InStanCeS.

Bank account holder (name as stated on bank account)

Bank account number/IBANSort code(if applicable)

SWIFT or BIC code(if applicable)

Bank name

Country

How long have you held this account? years months

− −

Bank address

Postcode

• Accounts within the UK, Jersey, Guernsey, Isle of Man or Gibraltar require a bank account number and sort code. • Premium payments made from banks outside the UK require a SWIFT or Bank Identifier Code (BIC), and an International bank account number (IBAN).

u the bank account must be in the name of the applicant(s).u Before completing this section, please refer to section G of the guidance notes for important information about your

payment and origin of wealth.u If you are making multiple payments, please photocopy this page, attach the details and the reason why multiple

payments are being made with this application form and tick here (3)

Additional information that may be required by the bank

Payment amount Payment currency

u�Before completing this section, please refer to section e of the guidance notes for information about paying your premium.

u�the premium payment must come from an account or transferred shares held in the name of the applicant(s).

u�the minimum initial investment amount is £25,000 (uS$37,500, €37,500 and other currency amounts as listed in the ‘at a glance’ document). Please remember to enclose a copy of receipt of your electronic bank transfer payment (for banking details see section e of the guidance notes), your asset transfer or share sale form (your financial adviser can provide you with the necessary details) with this application form.

Currency (3)

Amount to be invested

Payment method (3)

Are you paying your premium to Old Mutual International or is the premium to be paid by cash/asset transfer to an authorised custodian? (3)

Share saleElectronic bank transfer Asset transfer

Other (state currency)

£ US$ E

Old Mutual International Authorised custodian

d SOurCe Of fundInG

SOurCe Of fundS

e InVeStMent detaIlS

PreMIuM PaYMent

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You can appoint up to three authorised custodians to hold your assets or alternatively you can hold some of your assets with an authorised custodian and some of your assets with our default custodian. The details of the authorised custodian(s) need to be inserted in the table below and in addition you need to complete the ‘Request for Old Mutual International or Old Mutual International Ireland to appoint authorised custodian(s)’ form.

You can appoint a fund adviser or request Old Mutual International to appoint a discretionary asset manager to manage the assets held with your chosen authorised custodian(s). You should add their names into the table below and you must complete an appointment form for each fund adviser and/or discretionary asset manager you wish to appoint to manage the assets held by each custodian.

You financial adviser will be able to provide you with these forms.

Please note you must complete a form for each fund adviser and/or discretionary asset manager you wish to appoint to manage your assets. Your financial adviser will be able to provide you with the forms. Please tick which form(s) you are enclosing with this application form (3)

Request for Old Mutual International or Old Mutual International Ireland to appoint authorised custodian(s)

Appointing a fund adviser to your Old Mutual International - International Portfolio Bond or Old Mutual International Ireland European Portfolio Bond

default custodian – assets held by Old Mutual International

authorised custodian – assets held by an authorised third-party custodian

Please select the custodian(s) that will hold

the assets. (tick one option only (3))

Name of custodian(s)

Please enter the name of the fund adviser or discretionary asset manager you wish to appoint to manage the assets . You can only appoint one discretionary asset manager or one fund

adviser to each custodian.

Monetary Amount

Fund adviser Discretionary asset manager

Assets held by our default custodian Default N/A

Assets held by our default custodian and one other authorised custodian

Default N/A

Assets held by one authorised custodian

Assets held by two authorised custodians

Lead custodian:

Assets held by three authorised custodians.

Lead custodian:

Please complete the following with the details of how you would like your premium to be invested. Where assets are to be held by our default custodian and one other authorised custodian, we will subtract the amount shown for the authorised custodian from the overall premium amount, to determine the amount held with the default custodian.

Where you have appointed more than one authorised custodian you need to select a lead custodian who we will instruct to sell assets to pay for portfolio fund charges debited to the transaction account held with Old Mutual International. Please refer to your Policy Terms for further information on the portfolio fund charges debited to the transaction account held with Old Mutual International.

Please select the custodian(s) you would like to hold the assets linked to your policy:

Please note, if you have ticked one or both of the above, the trustees of the discounted gift trust need to complete the relevant form(s); both are available from your financial adviser.

f aSSet CHOICe

aPPOIntMent Of an autHOrISed CuStOdIan, fund adVISer Or dISCretIOnarY aSSet ManaGer

defInItIOnS

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Please note that you can invest in as many assets held with our default custodian as you wish, subject to a minimum of £400 (or currency equivalent). Some asset providers may have a higher minimum investment requirement and this minimum will prevail.

Please note if you are appointing a discretionary asset manager then please do not complete this section but please complete the Request for Old Mutual International to appoint a discretionary asset manager’ section on the next page.

Our default CuStOdIan

asset identifier ISIn

asset name – please enter names in full accumulation/Income unit requirement

(if applicable)

Share class

(if applicable for A,B or C)

Base currency of security/

fund(eg GBP, USD)

Investment %

Total 100%

Contact name

Daytime telephone number including area code Evening telephone number including area code

Fax number

E-mail address

In case we need to clarify the asset choice details above, please provide us with a contact name and telephone number.

Head OffICe uSe OnlY

Bond number net premium amount

f aSSet CHOICe (COntInued)

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Discretionary asset manager Regulatory Authority name and licence number

Name of discretionary asset manager

Discretionary asset manager registered address

Post code

1. I/We hereby request that the discretionary asset manager be appointed by Old Mutual International as discretionary asset manager to manage the assets/investments of the portfolio fund.

2. I/We understand that the management of the portfolio fund shall be at the discretion of the discretionary asset manager.

3. I/We acknowledge that I/we shall be responsible for any costs arising associated with the appointment of the discretionary asset manager and understand that the discretionary asset manager charges will be a charge against the portfolio fund as described in the Policy Terms.

The charges for this service are as follows:

% a year of the value of the portfolio fund to be taken quarterly;

or monetary amount £

The selected charge will be deducted in the bond currency and paid quarterly. Please refer to your Policy Terms for further information on discretionary asset manager charges.

Currently there is no VAT applicable to this charge, however Old Mutual International reserves the right to deduct from the portfolio fund any VAT or other tax that may become applicable to the charges in the future.

4. I/We have agreed with the discretionary asset manager the investment objectives in 4.1, 4.2 and 4.3 for the portfolio fund for which I/we will be wholly responsible. Old Mutual International will not be responsible for any investment strategy or objectives pursued by the discretionary asset manager or myself/ourselves but I/we understand that Old Mutual International does place restrictions on the types of investments that may be selected in accordance with the Policy Terms. If the investment objectives for the portfolio fund have already been provided on separate documentation then instead of completing 4.1, 4.2 and 4.3 below you can choose to enclose these documents with this application. If you wish to do this, then please confirm the name of this documentation below.

Name of documentation enclosed with this application

4.1 Investment strategy

4.2 Risk criteria

4.3 Investment restrictions

5. I/We understand that I/we will be responsible for monitoring the investments/assets held to ensure they align with my/our investment strategy, risk criteria and investment restrictions and I/we will inform Old Mutual International if these change. I/We understand that Old Mutual International can accept no responsibility for the effects of any delay or failure to inform them of any such change.

6. I/We confirm that I/we have received a copy of the Policy Terms and had the opportunity of reading them before completing this application.

Country

f aSSet CHOICe (COntInued)

reQueSt fOr Old Mutual InternatIOnal tO aPPOInt a dISCretIOnarY aSSet ManaGer

InVeStMent Mandate

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PLEASE TICK ThE DESCRIPTION OPTION(S) RELATING TO ThE ORIGINAL SOURCE OF ThE PREMIUM FOR YOUR POLICY. YOU MUST ALSO FULLY COMPLETE EACh RELEvANT SECTION RELATING TO ThE DESCRIPTION OPTION(S) YOU hAvE TICKED.

tHIS SeCtIOn MuSt Be COMPleted In all InStanCeS

continued

Length of time the shares/investment/policy held

Surrender penalty incurred (if any)

Total amount paid out Currency:

Amount:

Sale of shares

Maturing investments

Policy claim

replacement policy

Name of company that held your shares/investment/policy (ie bank, stockbroker or insurance company)

Name of person who held the shares/ investment policy

How were they sold? (ie bank, stockbroker or other agent, if applicable)

Description of shares sold (if applicable)

Reason for policy claim or replacement policy (if applicable)

Date received D D M M Y Y Y Y

G OrIGIn Of WealtH

full detaIlS Of OrIGIn Of WealtH

(3) deSCrIPtIOn detaIlS reQuIred YOur detaIlS

Total sale amount Currency:

Amount:

Sale of property Address of property sold (including postcode if applicable)

Date of sale D D M M Y Y Y Y

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PLEASE TICK ThE DESCRIPTION OPTION(S) RELATING TO ThE ORIGINAL SOURCE OF ThE PREMIUM FOR YOUR POLICY. YOU MUST FULLY COMPLETE EACh RELEvANT SECTION RELATING TO ThE DESCRIPTION OPTION(S) YOU hAvE TICKED.

u We may also require additional documentary evidence to support your application, particularly in relation to your country of residence and investment amount, before we can process it. Your financial adviser can establish if further documentary evidence is needed by completing part C in section l or by contacting us before sending in your application form. for a list of the types of documentary evidence we may need, please refer to section G of the guidance notes.

Please enter what documentary evidence you are enclosing with this application form (if applicable).

Total amount Currency:

Amount:

Details,including reasons where applicable (how the money was acquired etc) and for each of the description options shown below the specific information requested. Inheritance: Donor’s name, relationship to donor, date of donor’s death. Sale of interest in company: Name of company, nature of business, total sale amount, amount you received from the sale. loan: Name of loan provider, address of loan provider, reason for loan. Gift: Description of gift, reason for gift.Compensation: Reason for compensation. Competition or gambling win: How was the money acquired.

Origin of wealth (if ticked Other)

From which organisation or whom (state the relationship if applicable)

Date received

Other unearned income

Sale of interest in company

Inheritance

loan

Gift

Compensation

Competition or gambling win

Other

d d M M Y Y Y Y

G OrIGIn Of WealtH (COntInued)

full detaIlS Of OrIGIn Of WealtH

(3) deSCrIPtIOn detaIlS reQuIred YOur detaIlS

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u Before completing this section, please refer to section I of the guidance notes for information about the payment of adviser fees from your International Portfolio Bond.

Please enter the code for the Old Mutual International charge package that your financial adviser has explained will apply to your International Portfolio Bond

Do not use the illustration reference; only the appropriate Old Mutual International charging code should be used. Failure to provide the right code could result in the incorrect package being applied and/or delays.

Please confirm the initial fee to be facilitated by Old Mutual International, which you have agreed with your financial adviser. The initial fee will be facilitated by Old Mutual International before investment in your International Portfolio Bond. This means that we will deduct the fee from your lump sum premium payment before the remainder is invested in your International Portfolio Bond. Alternatively please tick the ‘No initial fee payable’ box where Old Mutual International is not to pay a fee to your financial adviser from your International Portfolio Bond.

Initial fee (monetary amount) or of initial premium

I wish the intial fee to be paid in the following currency (3)

No initial fee payable from your International Portfolio Bond

E£ US$ Other (state currency)

Please note – to pay a fee in a chosen currency, we must receive a premium payment in that currency that at least matches the amount of the fee. Also, paying an initial fee from your premium payment to us will reduce the premium invested and therefore the tax-deferred regular withdrawals you are able to take, which in turn reduces the discount available to you for the discounted gift trust. Please note there may be tax implications. We suggest that you discuss the above with your financial adviser before selecting your options.

£ %

Please enter the number of policies you would like:

tHe nuMBer Of POlICIeS CannOt Be CHanGed after tHe InternatIOnal POrtfOlIO BOnd IS Set uP.u If you do not specify the number of policies we will issue 12. If you require more or less, please refer to section H of

the guidance notes and insert the number required.

H nuMBer Of POlICIeS

I Old Mutual InternatIOnal CHarGeS and adVISer feeS

Old Mutual InternatIOnal’S CHarGeS

adVISer feeS

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You have chosen to invest in an International Portfolio Bond subject to a discounted gift trust. Based upon factors such as your age, sex, health and the level of regular withdrawals requested, Old Mutual International will calculate the estimated value of your right to receive the withdrawals. This value is known as ‘the discount’.

Please tick here if you wish to set your International Portfolio Bond live before the underwriting is complete (3)

u Please refer to section J of the guidance notes for more details on establishing your discount.

Have you ever applied for a discounted gift scheme and been advised of a nominal discount? (3)

Yes No Yes No

If Yes, please give details.

u Please note we may be unable to accept your application if you have been advised of a nominal discount.

Are you currently awaiting/undergoing any specialist investigations or in-patient treatment? (3)

Yes No Yes No


• heart disease, disorder or surgery?• Stroke or TIA (Transient Ischaemic Attack)?• Diabetes?

Do you suffer from or have you ever undergone treatment, investigations or operations for the following illnesses and conditions? (3)

Yes No Yes No

If Yes, please give details about the condition, the treatment and state the dates.

Are you able to live independently? (3) Yes No Yes No

Do you receive regular care assistance? (3) Yes No Yes No


• Cancer, hodgkin’s disease, lymphoma or leukaemia?• Dementia, Alzheimer’s disease or memory loss symptoms?• Any neurological disorder, loss of balance or falls?


J HealtH QueStIOnS (TO BE COMPLETED BY RECIPIENT(S) OF WITHDRAWALS)

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What is your:

or

Do you smoke cigarettes, or have you smoked in the last 12 months (3)

Yes No Yes No

FT IN IN

ST ST lbs lbs KG KG KG

Height:

Weight: or ST ST lbs lbs KG KG KGor

If Yes, what is/was your daily consumption?

a day a day

M CM CM or FT IN IN M CM CM

You only need to complete this authorisation to obtain a general practitioner’s report if you have a UK general practitioner (GP). It is important that you have visited your GP within the last 12 months in order for us to underwrite your discount. If you DO NOT have a UK GP, please complete the ‘Old Mutual International discounted gift trust additional medical questionnaire’.

Current doctor’s name and address

Telephone number including area code

Previous doctor’s name and address (if you have been registered with your current doctor for less than six months)

Telephone numberincluding area code

We will determine an estimated discount value of the gift based on the information you have given in the application form and the general practitioner’s report.

Postcode Country Postcode Country

Postcode CountryPostcode Country

J HealtH QueStIOnS (TO BE COMPLETED BY RECIPIENT(S) OF WITHDRAWALS) (COntInued)


YOur dOCtOr’S detaIlS (TO BE COMPLETED ONLY BY RECIPIENT(S) OF WITHDRAWALS)

autHOrISatIOn tO OBtaIn a General PraCtItIOner’S rePOrt


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I wish to see the report before it is sent to Old Mutual International (3)

Before we can ask any doctor that you have consulted to fill in a report, we need your permission under the Access to Medical Reports Act 1988. Your rights under the Act are as follows.

You do not need to give your permission, but if you do not, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance.

You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to keep the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us.

If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date.

If you think that any part of the report is not correct or is misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask them to attach a statement outlining your views, which will then accompany the report.

Your doctor can withhold access to the report if they feel that it would cause physical or mental harm to you or others.

If you have any questions about your rights under the Act or questions relating to the process of getting, assessing or storing medical information, please write to our Head Office.

I do not wish to see the report before it is sent to Old Mutual International (3)

I/We have been informed of my/our statutory rights under the Access to Medical Reports Act 1988 and the Access to Personal Files and Medical Reports (N.I.) Order 1991. In connection with the contract currently applied for, I/we consent to Old Mutual International Isle of Man Limited seeking medical information from any doctor who at any time has attended me/us concerning anything which affects my physical or mental health within six months of the start of the bond. I agree that a copy of this consent will have the validity of the original.

Full name

Signature of applicant 1

Date D D M M Y Y Y Y

Full name

Signature of applicant 2 (if any)

Date D D M M Y Y Y Y

If you do not tick a box we shall assume that you do not wish to see your medical report.

YOur rIGHtS Of aCCeSS tO MedICal rePOrtS

eaCH aPPlICant SHOuld tICK One BOX OnlY.

deClaratIOn


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I understand that Old Mutual International Business Services, Old Mutual International Isle of Man Limited and/or Old Mutual International Ireland dac (Old Mutual International) will process personal information about me and any other party whose personal information I have provided.

The type of personal information processed about me will depend on the purpose for which it has been collected and will include:

• my contact details

• information to verify my identity

• information about my family, lifestyle, health and finances

• my payment details.

The processing of my personal information may take place in a number of jurisdictions and may be shared with other parties within or outside the Old Mutual Wealth group of companies for the general purpose of establishing, maintaining and servicing an insurance policy.

The sharing of my personal data may be used for any or all of the following purposes, to:

• check against credit reference or other databases to verify information provided for regulatory due diligence purposes and to prevent or detect financial crime including money laundering, terrorist financing, bribery and corruption, sanctions listing or fraud;

• allow for the provision of services relating to enhanced due diligence, underwriting, reinsurance, data hosting, online services, payment or reporting of any tax or levy, or any other services provided from time to time;

• enable an appointed financial adviser or fund adviser to assist in the provision of services to the policyholder;

• compile statistical analysis or market research, where information is not specific to the individual;

• comply with any legal obligation which includes the releasing of personal information to regulators, law enforcement authorities or other bodies where there is a legal requirement to do so, including the sharing of information under regulations relating to the U.S Foreign Account Tax Compliance Act and The Organisation for Economic Co-operation and Development Common Reporting Standard;

• enable an appointed discretionary asset manager or custodian to meet their legal or regulatory requirements, where that discretionary asset manager or custodian providing services in relation to a policy requests the personal data of an individual linked to an application, and where we are satisfied that such a discretionary asset manager or custodian has a legal or regulatory requirement to make such a request.

Where my personal information is shared with a third party for the provision of services relating to my policy, my personal information will only be used for the purposes for which it was collected. In some circumstances this may involve a transfer of my personal information to a third party outside the European Economic Area (EEA). Whenever my personal information is shared it will be subject to the same levels of security and protection that Old Mutual International would apply.

I may ask Old Mutual International to:

• provide a copy of personal information held about me and an explanation of how this data is processed;

• update or correct my personal information;

• delete information about me (where it is no longer necessary in relation to the purpose for which it was originally collected);

• restrict processing of my personal information where appropriate. I may also object to Old Mutual International processing my data but understand that this may have consequences in Old Mutual International being able to continue servicing my policy.

I have been made aware that a full explanation of how Old Mutual International collects, uses and shares my personal information can be found at www.oldmutualinternational.com

If I have any questions about data privacy I can address these to:

For Old Mutual International Isle of Man Limited: The Data Protection Officer, Old Mutual International Isle of Man Limited, King Edward Bay house, King Edward Road, Onchan, Isle of Man, British Isles, IM99 1NU.

For Old Mutual International Ireland dac: The Data Protection Officer, Old Mutual International Ireland dac, hambleden house, 19-26 Lower Pembroke Street, Dublin 2, DO2 Wv96, Ireland.

If I have a complaint about the processing of my personal information and Old Mutual International is unable to provide a satisfactory response I may contact the appropriate regulator:

For Old Mutual International Isle of Man Limited: The Isle of Man Information Commissioner, First Floor, Prospect Hill, Douglas, Isle of Man, IM1 1ET.

For Old Mutual International Ireland dac: The Ireland Data Protection Commissioner, Canal house, Station Road, Portarlington, R32 AP23 Co. Laois, Ireland.

I have read and understood the Data Privacy Statement set out above and will make it available to other individuals whose personal information has been provided by me to Old Mutual International either in this application or within accompanying documentation.

K deClaratIOn and aPPlICatIOn

data PrIVaCY StateMent

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Signature of applicant 1 Date

Please enter the country in which this application form was completed.

D D M M Y Y Y Y

D D M M Y Y Y Y

A copy of this completed application form is available on request.Old Mutual International Isle of Man Limited will be referred to as Old Mutual International throughout this declaration.1 I understand and agree that I am applying to enter a new contract with Old Mutual International, it will be subject to the laws of the Isle of Man and

the Policy Terms will be in the English language.2 I request that the lump sum referred to as a premium is invested as I have instructed as an initial premium for policies comprising either an

Old Mutual International - International Portfolio Bond – Life PRIIPs (ref IPBv3) or an Old Mutual International - International Portfolio Bond – Redemption PRIIPs (ref IPBRv3), and I request Old Mutual International to issue the policies in my name, jointly with the other applicants, if any.

3 I declare to the best of my knowledge and belief that the statements made in this application, and any related documents, are true and complete. I have not concealed a material fact. I agree to provide Old Mutual International with any further information in respect of this application on request.

4 I confirm that Old Mutual International has not provided any investment advice and I or my fund adviser are responsible for the selection of assets to be linked to my Portfolio Fund. I acknowledge that Old Mutual International is not responsible for any loss suffered or reduction in the value of my Policy arising from my investment. Old Mutual International does not have any responsibility for the management of the underlying assets chosen other than Internal Funds, which are invested in accordance with the criteria as published in the relevant fund factsheet and carrying out a treasury function in respect of the Transaction Account and Old Mutual International does not recommend any asset as a suitable investment.

5 I confirm that I am not a resident of the United States of America or any of its territories. If I become resident in the United States of America or any of its territories, Old Mutual International may not be able to accept any further premiums until after I cease to be a resident in the United States of America or any of its territories.

6 I confirm that I have received a copy of the following items and I have had the opportunity to read them before reviewing and signing this application: Key features of your Old Mutual International - International Portfolio Bond, Details of your Old Mutual International - International Portfolio Bond – Redemption PRIIPs (ref IPBRv3) or Details of your Old Mutual International - International Portfolio Bond – Life PRIIPs (ref IPBRv3) Policy Terms, Unlocking the secrets of intelligent investing – product brochure, the International Portfolio Bond – Redemption or International Portfolio Bond – Life ‘at a glance’ documents and Explaining your Portfolio Bond fees and charges, Key Information Document (KID) for the policy and Fund Key Information Document(s) (KIDs) and, where appropriate, the Fund Key Investor Information Documents (KIIDs). Furthermore, I agree that where I choose to change assets of the portfolio fund in future, I will ensure that I will obtain Fund Key Information Document(s) for those assets before they are purchased.

7 I authorise and request Old Mutual International to effect the facilitation of any initial fee to be taken before my investment is paid into the Policy, if applicable to my application, and I confirm that such payments will discharge Old Mutual International from all liabilities and claims arising from the payment of that initial fee. I understand that this authority supersedes any authority previously given.

8 I may wish to invest into professional/non-retail type investment schemes and, if so, I will make sure that I have had the opportunity to read the offering documents for funds of this nature. Where I decide to invest in professional/non-retail type investment schemes, I accept the levels of risk associated with these, including the risk that the investment into such a scheme could result in a loss of a significant proportion, or all, of the sum invested.

9 I understand that in cases where the asset(s) I have selected is/are not redeemable for a certain period of time, Old Mutual International may not be able to return that part of my payment until the end of that period. The description of the funds and/or assets I have chosen will give details if this applies. I may invest immediately into non daily dealing funds with the understanding that in the event of cancellation or requiring early access that:

(a) I may not get my money back immediately and payment may be delayed for some time; (b) the institution may impose penalties and therefore I may get back less than I invested, and/or (c) the only way in which to receive value may be through a transfer of the ownership of that asset into the name of the Policyholder.10 I appoint the financial adviser to act on my behalf in accordance with the Policy Terms.11 I confirm that where this application is for an International Portfolio Bond – Life each life assured (or their parent where parental consent is required)

consents to this application, and agrees to my acting as their agent for the purpose of the information provided in this application.12. The Premium detailed in this application and any other Premium tendered in respect of this application are derived solely from the source of funding

provided and have, where required, been declared to the relevant tax authority in my country of residence for taxation.13. The application for an Old Mutual International policy is not being made for the purpose of concealing funds, assets or wealth with a view to the

evasion of any taxes I am obliged to pay.

This application must be completed by the applicant(s) unless you have asked your financial adviser to complete it.

Did you complete this application form yourself? (3)

If No, did a third party, such as your financial adviser, complete it on your behalf? (3)

By signing this declaration you confirm that you have read through the above declaration and, if a third party has completed the application form on your behalf, that all the information provided in it is correct.

Yes No

Yes No

Please read the declaration on this page carefully.Any omission or misstatement of a material fact in this application could affect the payment of benefits under the International Portfolio Bond – Life PRIIPs or International Portfolio Bond – Redemption PRIIPs. A material fact is one which is likely to influence the assessment and acceptance of the application. If you are uncertain whether a fact is material, you should give full details so that we can assess its possible significance. If you become aware of such a fact while we are considering your application, you should notify us immediately.You should satisfy yourself that you are able to effect the proposed contract under any taxation, exchange control or insurance law to which you may be subject.

K deClaratIOn Of aPPlICatIOn (COntInued)

WarnInG

deClaratIOn – BY eaCH aPPlICant

Signature of applicant 2 Date

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tHIS SeCtIOn MuSt Be COMPleted WHeneVer dOCuMentarY eVIdenCe IS SuBMItted. u Please note that we will not be able to commence your policy until this section has been completed and you have

provided the necessary identification documentation. Please refer to sections l and M of the guidance notes for more information on certifying documents.

Outlined below are the standard minimum requirements. In some circumstances we may need additional information.

We require one document from part A and one from part B. If neither document in part A is available, please provide the reason why and provide two formal documents showing appropriate personal details and verifiable reference numbers from part B. When certifying copies of original documents, the suitable certifier must provide the following: • a statement to reflect that it is a true copy of the original • their name • their signature • the date of certification

Identification documentation should be current and valid. evidence of address should be the latest available, but no more than three months old.u Please tick (3) to indicate the identification you have supplied for each individual party to the bond. If a fund adviser

has been appointed we may need to verify the identity of the appointee.

Part a – reaSOn WHY dOCuMentS are nOt PrOVIded (IF APPLICABLE)

1. Name

Capacity

Type of document Passport National identity card

Document reference

Part a IndIVIdual WHOSe IdentItY IS BeInG VerIfIed

2. Name

Capacity

Type of document Passport National identity card

Document reference

continued

these must be less than three months old 1 2 1. A recent utility, rates or council tax bill (mobile/cell phone bills not acceptable)

2. A recent mortgage statement, giving the residential address

3. An extract from the official register of electors

4. A state pension, benefit or other government produced document showing benefit entitlement

5. A recent tax assessment document

6. A recent account statement from bank or credit card (store cards not acceptable)

7. Proof of ownership or rental of the residential address

Part B IndIVIdual WHOSe reSIdentIal addreSS IS BeInG VerIfIed

l VerIfICatIOn Of CuStOMer IdentItY (FINANCIAL ADVISER/SUITABLE CERTIFIER TO COMPLETE)

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u Please refer to the origin of wealth guidelines (available from Old Mutual International) for information on how to complete the table below and section G of the guidance notes for information about the documentary evidence we may need.

To prevent financial crime, Isle of Man authorised life companies adopt a ‘risk-based approach’ when obtaining evidence of the origin of a client’s wealth. In order to speed up the application process we have provided you with the table below to allow you to find out your client’s risk rating before submitting the application form to us. We highly recommend that you complete the risk rating as it allows you to determine if you need to enclose further documentary evidence with the application form or not. If we do not receive the necessary documentary evidence with the application form, then it will take longer to process the business.

In order to decide what risk rating applies to your client’s investment you need to take into account the following factors:

(a) your client’s country of residence

(b) which country the premium is paid from

(a) + (b) = total risk rating

Old Mutual International reserves the right to request further documentation if it is felt appropriate. Please note that each new application will be reviewed individually.

If you are unsure about a particular application, please contact your Old Mutual International business consultant in the first instance, or alternatively contact Old Mutual International’s International Sales Support team directly on +44 (0)1624 655 010.

Applicant

Example

Client country of residence (a)

UK (1)

Country of premium funding (b)

UK (1)

Total risk rating

2

l VerIfICatIOn Of CuStOMer IdentItY (FINANCIAL ADVISER/SUITABLE CERTIFIER TO COMPLETE) (COntInued)

Part C fInanCIal CrIMe – rISK ratInG

19 of 20

tHIS SeCtIOn MuSt Be COMPleted In all InStanCeS.

I declare that:• I have verified the contents of the original documents where copies have been enclosed and confirm that they are true copies of the original.• I have taken reasonable steps to make sure that the funding is legitimate and in line with the client’s circumstances. • To the best of my knowledge and belief, all the information provided in and with this application is true and complete and was obtained from the

applicant(s) who is/are of good standing. I also confirm I will provide further information if required.• I have not made any changes to the application form after the client has signed it.

I confirm that I gave advice concerning this investment to the applicant(s) in Country

on the following date

Date

Financial adviser stamp

I confirm that, if applicable, all information provided was received directly from the applicant(s).

Regulatory body authorisation number (if applicable)

Regulator name

Old Mutual International financial adviser account number

Full name of introducer firm

Full name of financial adviser/suitable certifier

Signature of financial adviser/suitable certifier

D D M M Y Y Y Y

D D M M Y Y Y Y

M fInanCIal adVISer/SuItaBle CertIfIer deClaratIOn

deClaratIOn BY tHe fInanCIal adVISer/SuItaBle CertIfIer

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www.oldmutualinternational.comCalls may be monitored and recorded for training purposes and to avoid misunderstandings.

Old Mutual International Isle of Man Limited is registered in the Isle of Man under number 24916C. Registered and head Office: King Edward Bay house, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0)1624 655 555 Fax: +44 (0)1624 611 715.

Licensed by the Isle of Man Financial Services Authority.

All promotional material is approved by Old Mutual Wealth Limited. Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Financial Services register number 165359.

The rules made under the Financial Services and Markets Act 2000 (as amended) for the protection of retail clients in the UK do not apply.

Old Mutual International Isle of Man Limited is a member of the Association of International Life Offices.

Old Mutual International is registered in the Isle of Man as a business name of Old Mutual International Isle of Man Limited.

When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well managed, sustainable forests.

SK14436/INT18-0492/May 2018