Additional Investment

This form is for use with the following: International Investment Bond International Investment Account International Savings Plan International Investment Plan Guernsey International Pension UltimaBond UltimaSave Flexible Savings Plan Flexible Investment Plan Versatile Investment Plan

J22307_XGU02F_HL65001_1017.indd 1 30/08/17 3:12 pm Part 1 – Introduction – It is most important that you read this part before completing the application form. • Please use BLOCK CAPITALS throughout and tick the boxes where appropriate.

• If you make a mistake please cross it out, put in the correct word or words and initial next to the correction.

• Incorrect or incomplete application forms may delay the processing of this proposal. This may also result in the form being returned for completion.

Part 2 – Details of Existing Policy

Policyholder name(s)

Policy number

If you have changed your address since effecting the existing policy please provide the details below.

Current residential address (including street name, town and area code if known)

Email address

Contact telephone number

Part 3 – Financial Adviser Details

Company name

Contact details for acknowledgement/queries on the application.

Contact name

Telephone number

Email address

Country where advice given

Country where application signed

Part 4 – Details of Additional Investment

Regular Single

Amount of additional investment

Minimum contribution Regular Single International Investment Bond n/a GBP 5,000 / USD 7,500 / EUR 7,500 International Investment Account GBP 50pm / GBP 600pa GBP 5,000 International Savings Plan GBP 50pm / GBP 600pa GBP 2,500 International Investment Plan GBP 50pm / GBP 600pa GBP 2,500 Guernsey International Pension GBP 50pm / GBP 600pa GBP 2,500 UltimaBond n/a GBP 5,000 / USD 10,000 / EUR 7,500 UltimaSave GBP 20pm / GBP 240pa GBP 500 USD 40pm / USD 480pa USD 1,000 EUR 30pm / EUR 360pa EUR 650 Flexible Savings Plan GBP 10pm / GBP 100pa GBP 500 Flexible Investment Plan GBP 10pm / GBP 100pa GBP 1,000 Versatile Investment Plan GBP 35pm / GBP 350pa n/a

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J22307_XGU02F_HL65001_1017.indd 2 30/08/17 3:12 pm Part 4 – Details of Additional Investment (continued) Additional regular premium investments will be increased with effect from the next monthly or annual payment date. If your existing policy is written as a cluster of policies, your additional investment will be split equally between them. Each cluster is subject to the minimums shown in this section on page 2.

Fund choice

Please confirm which fund(s) you wish your increment to be invested in. Up to ten funds can be selected, including those in which you are already invested. For further information on funds please contact us. Our contact details can be found in the section ‘How to Contact Us’ on page 12. If this section is left blank we will assume you wish the fund choice to remain the same as your existing policy. Please use whole percentages only.

Guernsey International Pensions only: Additional single contributions into the With Profit fund are only permitted provided the plan has a minimum of 10 years to run.

Use existing fund selection. (Please tick if applicable.)

Fund Manager Fund Name Currency % of contribution

TOTAL 100%

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J22307_XGU02F_HL65001_1017.indd 3 30/08/17 3:12 pm Part 5 – Trusts

If the existing policy is written under trust, the trustees must sign this application authorising the additional investment. If there are more than two trustees, please submit this section from another form. Trustee Trustee

Name

Signature

Date (DD/MM/YY)

Part 6 – Declaration by the policyholder(s) – as named in the policy schedule

l/We wish to make an additional investment into my/our policy, the details of which are shown above in accordance with the Policy Conditions. l/We understand that this will take effect upon acceptance of the application by Friends Provident International. l/We declare that any information and advice about this product given by my/our Financial Adviser was given only following my/our approach to the Financial Adviser requesting information and advice on life assurance contracts offered by Friends Provident International.

Signature of first policyholder and date (DD/MM/YY)

Signature of second policyholder and date (DD/MM/YY)

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J22307_XGU02F_HL65001_1017.indd 4 30/08/17 3:12 pm Part 7 – Verification of Identity and Source of Funds (VISF) for Individuals Important note One VISF form must be completed for each individual, ie Applicant(s), Premium Payer(s).

Guidance notes on how to complete this form and additional VISF forms are available in the ’IFA’ section of our website, www.fpinternational. com or by contacting us on +44(0) 1722 415088. The adviser must complete both sides of this form. It forms the prevention of money laundering check and is essential to the acceptance of this application. It will delay the processing of this application if not completed fully and correctly.

Section A – Verification subject: Individual

Please see appropriate ID and Residency guide for list of acceptable documentation.

Full name Occupation

Nature of Employer’s business

Customer Type, please tick one of the boxes below: Premium Payer/ Applicant Other Joint account holder (ie Protector, Director, Shareholder, Settlor, Trustee or Major Beneficiary) Please go to section B Please go to section D Please go to section D

If the verification subject is not an applicant, please go straight to section D.

Section B – Source of Funds

Please tick one of the following:

I can confirm the premium is:

Originating from the account details provided on the credit card mandate, direct debit mandate or cheque. If this is being paid by third party please proceed to section C.

Being paid by telegraphic transfer and that it originates from the bank details provided below. Account holder Bank name name(s) and address

Account number

Sort Code/ Swift Number

If this is a third party please proceed to section C.

Being paid by a banker’s draft. I enclose proof of purchase/remittance advice with the application. If this is being paid by a third party please proceed to section C.

Originating from a matured/surrendered policy or a withdrawal payment from the details below.

Product provider Policyholder name name(s)

Policy number

If this is a third party please proceed to section C.

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J22307_XGU02F_HL65001_1017.indd 5 30/08/17 3:12 pm Section C – Third Party Paying the Premium

As the premium is being paid by a third party you must complete the questions below and a separate Verification of Identity or Source of Funds form, sections A and D. 1 Please confirm the relationship between the applicant(s) and premium payer(s)

2 Please provide a detailed explanation why the premium is not being paid by the applicant

3 If the premium originates from the applicant’s account via a third party account then you must provide the applicant(s) bank details below.

Account holder Bank name name(s) and address

Account number

Sort code/ Swift code

Section D – Verification of Identity and Proof of Residential Address

Please see appropriate ID and Residency guide for list of acceptable documentation. Please tick one of the following:

I am claiming the Small Premium Exemption as this premium and any premiums from existing policies the customer has, does not exceed £50pm or £600pa. I understand that if the premium exceeds the limits given above, I will be asked to fully complete a Verification of Identity and Proof of Residential address check for the individual. OR

I have verified the identity of the individual overleaf and can confirm that I have seen the original document(s) specified. The document(s) were pre-signed and the photographs bears a true likeness.

Verification of Identity Proof of residential address

Type of document seen

Reference number

Issue date (DD/MM/YY)

Expiry date (DD/MM/YY)

Issuing authority

IFAs outside of the EU, Channel Islands, Isle of Man, Iceland and Gibraltar must provide certified copies of documentary evidence. The document used to verify identity must not be the same as the document used for proof of residential address.* *Please note that we can no longer accept a credit card statement as proof of address.

I/We hereby confirm that: A evidence of the identity of the above has been seen in accordance with the provisions of the European Council Directive 91/308/EEC and relevant national legislation. B (if premium exceeds £50pm or £600pa) I/we have identified the above and confirmed that I/we have seen the original document(s) specified, the document(s) were pre-signed and the photograph(s) bear a true likeness. C I/we am/are unaware of any activities on the part of the above customer(s) which lead me to suspect that the customer is or has been involved in criminal activity or Money Laundering. Should I/we subsequently become suspicious of any such activity, I/we shall advise you immediately. D I/we am/are satisfied that we could physically locate the residential address(es) by way of a recorded description or other means. E the particulars given and statements made within the Source of Funds and Verification of Identity sections are to the best of my/our knowledge and belief true.

Financial Adviser Signed Full name, please print Date (DD/MM/YY)

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J22307_XGU02F_HL65001_1017.indd 6 30/08/17 3:12 pm Verification of Identity and Source of Funds (VISF) for Non Individuals Important note Guidance notes on how to complete this form and additional VISF forms are available in the ’IFA’ section of our website, www.fpinternational.com or by contacting us on +44(0) 1722 415088.

The Financial Adviser must complete both sides of this form. It forms the prevention of money laundering check and is essential to the acceptance of this application. It will delay the processing of this application if not completed fully and correctly.

Section A – Verification subject: Non Individual

Name Nature of Company’s Registration business number Regulatory Organisation

Type of Legal Entity, please tick one of the boxes below. Private Limited Public Limited Charity Local Authority Company Company Government Partnership Sole Trader Church Department

Customer type Premium Payer/ Applicant Other Joint account holder Please go to section B Please go to section D (ie Protector, Director, Shareholder, Settlor, Trustee or Major Beneficiary)

Please go to section D

If the verification subject is not an applicant, please go straight to section D.

Section B – Source of Funds

Please tick one of the following:

I can confirm the premium is: Originating from the account details provided on the credit card mandate, direct debit mandate or cheque. If this is being paid by third party please proceed to section C.

Being paid by telegraphic transfer and that it originates from the bank details provided below.

Account holder Bank name name(s) and address

Account number

Sort Code/ Swift Number

If this is a third party please proceed to section C.

Being paid by a banker’s draft. I enclose proof of purchase/remittance advice with the application. If this is being paid by a third party please proceed to section C.

Originating from a matured/surrendered policy or a withdrawal payment from the details below.

Product provider Policyholder name name(s)

Policy number

If this is a third party please proceed to section C.

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J22307_XGU02F_HL65001_1017.indd 7 30/08/17 3:12 pm Section C – Third Party Paying the Premium

3 If the premium originates from the applicant’s account via a third party account then you must provide the applicant(s) bank details below. Account holder Bank name name(s) and address

Account number

Sort code/ Swift code

Section D – Verification of Identity and Proof of Registered Address

I have verified the identity of the ‘non-individual’ overleaf. Details below.

Evidence of Identity Please complete one of the following:

Private Limited Company Certificate of Incorporation seen Registered Number Country of Origin Date of Incorporation (DD/MM/YY)

Yes No

Public Limited Company Stock Exchange Stock Exchange Daily Official Check completed List (SEDOL) number Date of Check (DD/MM/YY) Yes No

Partnership Partnership agreement seen Reference Number Country of Origin Date of Agreement (DD/MM/YY)

Yes No

Sole Trader Evidence of Business Name seen Type of document seen Date of issue (DD/MM/YY) Yes No

Evidence of Address Please complete one of the following: Visit to Business Premises (IFAs within UK, EU, CI, IOM, Iceland and Gibraltar only) Date of visit (DD/MM/YY) Premises entered? Yes No Yes No

Bank Statement seen* Reference Number Name of Issuer Date of Issue (DD/MM/YY)

Yes No

Utility Bill Reference Number Name of Utility Company Date of Issue (DD/MM/YY)

Yes No

IFAs outside of the EU, Channel Islands, Isle of Man, Iceland and Gibraltar must provide certified copies of documentary evidence.

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J22307_XGU02F_HL65001_1017.indd 8 30/08/17 3:12 pm Section D (continued) – Additional Identity Information

Please provide a list of Shareholder/Directors/Partners/Signatories/Controllers/beneficial owners (as applicable). Not required for Public Limited Companies, Sole Traders, Local Authority or Government Departments

Name Status %

Please see guidance grid on page 10 for possible further information required.

I/We hereby confirm that:

A evi dence of the identity of the above has been seen in accordance with the provisions of the European Council Directive 91/308/EEC and relevant national legislation.

B (if premium exceeds £50pm or £600pa) I/we have identified the above and confirmed that I/we have seen the original document(s) specified, the document(s) were pre-signed and the photograph(s) bear a true likeness.

C I/we am/are unaware of any activities on the part of the above customer(s) which lead me to suspect that the customer is or has been involved in criminal activity or Money Laundering. Should I/we subsequently become suspicious of any such activity, I/we shall advise you immediately.

D I/we am/are satisfied that we could physically locate the residential address(es) by way of a recorded description or other means. E the particulars given and statements made within the Source of Funds and Verification of Identity sections are to the best of my/our knowledge and belief true.

Financial Adviser Signed Full name, please print Date (DD/MM/YY)

* Please note that we can no longer accept a credit card statement as proof of address. Declarations

Data protection Financial Crime (e.g. verifying your identity to prevent Fraud & Money Laundering) Friends Provident International is part of the Aviva group of companies. The Aviva group will use my information supplied To verify your identity and prevent financial crime we may use and by me. I understand that Friends Provident International may share your information with any company trading under the name pass my information to other companies within Aviva group for Friends Provident International, with companies who work for us administration, research or statistical purposes. I also agree that and with appropriate organisations. Friends Provident International may pass my information to my Financial Adviser, re-assurers, such other third parties as may be We may also search, send your details to, and use information from necessary to assist in the provision and administration of my policy, third party verification service providers and financial crime and including those located outside of the European Economic Area and credit reference agencies (Third Parties). This involves checking where we are legally required to provide information (e.g. requests your details against databases these Third Parties use. Friends from government agencies). By signing this form, I consent to this Provident International and these Third Parties may keep a record use of my personal data as set out above. of the search, the results of the search, any suspicions of financial crime and the details may be used to assist other companies for I understand that Friends Provident International would like to verification and identification purposes. The search is not a credit keep me informed about other products and services provided check and your credit rating should be unaffected. by companies within Aviva group and other carefully selected organisations. By signing our application form, you are giving consent to these activities which will make it easier for you to do business with us I do not wish you to contact me by: and help prevent financial crime. For more information, please write to: Head of Anti Money Laundering & Sanctions, Financial Crime Post Phone Email (BM6L2), Aviva Centre, Brierly Furlong, Stoke Gifford, Bristol BS34 8SW. You can change your mind at any time by contacting us. Our contact details can be found in the section ‘How to Contact Us’ on page 12.

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J22307_XGU02F_HL65001_1017.indd 9 30/08/17 3:12 pm Guidance Grid

Additional Identity Information

Type of Legal Entity IFAs Inside the EU, Channel Islands, Isle of Man, IFAs Outside the EU, Channel Islands, Iceland and Gibraltar Isle of Man, Iceland and Gibraltar

For companies inside the EU/ For companies outside the EU/ CI/IOM, Iceland & Gibraltar CI/IOM, Iceland & Gibraltar

Private Limited Fully completed Verification of Fully completed Verification of Fully completed Verification of Identity and Company Identity and Source of Funds Identity and Source of Funds Source of Funds form for Non-Individuals and form for Non-Individuals form for Non-Individuals supporting documentary evidence

Certified copy of list of Completion of a Verification of Completion of a Verification of Identity & Source signatories* Identity & Source of Funds of Funds form for Individuals and supporting form for Individuals for all of documentary evidence for all of the following: the following: • Shareholders with 25% interest or more • Shareholders with 25% interest or more • Any ultimate beneficial owners

• Any ultimate beneficial • At least two directors owners List of authorised signatories* • At least two directors List of authorised signatories*

Public Limited Fully completed Verification of Fully completed Verification of Fully completed Verification of Identity and Company Identity and Source of Funds Identity and Source of Funds Source of Funds form for Non-Individuals and form for Non-Individuals form for Non-Individuals supporting documentary evidence

List of authorised signatories* Confirmation in writing that the Certified copy of the company’s latest reports company’s latest reports and and accounts accounts have been seen List of authorised signatories* List of authorised signatories*

Partnership Fully completed Verification of Identity and Source of Funds form Fully completed Verification of Identity and for Non-Individuals Source of Funds form for Non-Individuals and supporting documentary evidence Completion of a Verification of Identity & Source of Funds form for Individuals for all of the following: Completion of a Verification of Identity & Source of Funds form and supporting • All principal owners & controllers documentary evidence for individuals for all of the following: • At least two authorised signatories • All principal owners & controllers Certified copy of the authorised signatory list, or a list of directors • At least two authorised signatories

Certified copy of the authorised signatory list or a list of directors

Sole Trader Fully completed Verification of Identity and Source of Funds form Fully completed Verification of Identity and for Non-Individuals Source of Funds form for Non-Individuals and supporting documentary evidence NOTE: Documents to evidence business name include: bank statement, cheque or company letterhead NOTE: Documents to evidence business name include: bank statement, cheque or Completion of a Verification of Identity & Source of Funds form for company letterhead Individuals, for the company owner Completion of a Verification of Identity & Source of Funds form for Individuals, for the company owner and supporting documentary evidence

Charity/Church/ Please contact Friends Provident Club/Society/ International IFA Support for guidance Local Authority on +44 (0)1722 415088 or Government Department

For more information visit www.fpinternational.com *Please note: If a company is to be the policy owner, a certified copy of the list of authorised signatories is required. The authorised signatory list provides Friends Provident International with information on who is able to sign on behalf of the company. The document should be on company headed paper and show the specimen signatures of all name individuals.

XGU02/F HL65001 10/2017 Page 10

J22307_XGU02F_HL65001_1017.indd 10 30/08/17 3:12 pm Part 8 – Additional Investment Payment Details Please provide details of the additional investment payment below. Tick as applicable. Direct debit I authorise you to deduct the increased amount given in Part 4 using the existing bank details you hold. Only available for monthly and annual premium increments.

Credit card Please complete the credit card mandate below. Only available for monthly and annual premium increments.

Credit Card Authority We can only accept Mastercard or Visa

Until further notice in writing, I authorise Friends Provident International to charge my MASTERCARD/VISA* account a single unspecified sum followed by on or immediately after (please insert date (DD/MM/YY)) MONTHLY/ANNUALLY* thereafter. (*delete as appropriate.)

Card number Valid from Expiry date

Cardholder’s name MM / YY MM / YY and initials as shown on card

Cardholder Signature statement address Dated

DD / MM / YY

Telegraphic Transfer If payment has already been made to our bank account, please provide us with the details below.

Transfer date Transfer amount (DD/MM/YY)

Transfer reference

Surrender or Withdrawal payment from a Friends Provident policy

Policyholder(s) name(s) Policy number Policyholder(s) name(s)

XGU02/F HL65001 10/2017 Page 11

J22307_XGU02F_HL65001_1017.indd 11 30/08/17 3:12 pm Important Notes The information given in this document is based on Friends Provident International’s understanding of current UK law and taxation practice, which may change. No liability can be accepted for any personal tax consequences of this scheme and for the effect of future tax or legislative changes.

Fund prices may go up and down depending upon investment performance, and are not guaranteed. Please note that securities held within a fund may not be denominated in the currency of that fund and, as a result, fund prices may rise and fall purely on account of exchange rate fluctuations. You may get back less than you have paid in.

Property is an illiquid asset. Where a fund invests in properties, sometimes the properties may not be easy to sell and this means that the fund cannot guarantee to be completely liquid during the lifetime of your investment in it. It must be recognised that an investment in a fund of this type may have liquidity constraints in the future that may lead to delays in the switching or liquidation of fund units. Complaints we cannot settle can be referred to the Financial Services Ombudsman.

Some telephone communications with the company are recorded and may be randomly monitored or interrupted. How to Contact Us

Please call us on +44(0) 1722 415088 or email [email protected] and we will be happy to assist.

Friends Provident International is a business name of Friends Provident International Limited and Aviva Life & Pensions UK Limited for business conducted outside the United Kingdom. Aviva Life & Pensions UK Limited Registered in England No.3253947. Registered office: Aviva, Wellington Row, York, YO90 1WR. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number 185896. Salisbury Office: United Kingdom House, Castle Street, Salisbury, Wiltshire SP1 3SH England. Telephone +44(0) 1722 415 088 Fax +44(0) 1722 332 005 Email [email protected] Website www.fpinternational.com Friends Provident International is a registered trade mark of the Aviva group.

XGU02/F HL65001 10/2017

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