Please enter the number of the plan you wish to make/amend contributions to:

Plan Number

Scheme name

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ADDING OR AMENDING CONTRIBUTIONS– Initial Price Executive Pension (EP5)

WITH THIS FORM YOU CAN:

– make a contribution into your existing plan– set up or amend a regular contribution into your existing plan.This form cannot be used for:– for making transfers in from other pensions.

We regularly update our forms; your financial adviser can confirm this is the latest version by checking the literature library on our website www.reassure.co.uk

COMPLETING THIS FORM

• Complete this form using BLOCK CAPITALS and blue or black ink. For dates, please use the format day/month/year.• Missing or unclear information may result in a delay in processing, or even the return of this form. We are unable to correct errors or

omissions by you or your financial adviser retrospectively.• All references to ReAssure in this form mean ReAssure Life Limited.• Before completing the form, please refer to the flow chart on page 3. It contains information about whether this application will convert your

plan to Adviser Charging.

PAYMENT DETAILS• Single contributions may be made by electronic bank transfer or cheque.

Please send a bank transfer to ReAssure Life Limited.

Bank: NatWest. Sort code: 56-00-68. Account number: 00053937.

In the reference field on your bank transfer please enter your plan number and surname to help us process your application.

Alternatively, you may send a cheque payable to ReAssure Life Limited.

• Regular contributions will be collected by Direct Debit, and will require a completed Direct Debit mandate found at the back of this form.

SEND YOUR COMPLETED FORM AS FOLLOWS:• Once complete, this form should be signed and sent to:

ReAssure, Old Mutual House, Portland Terrace, Southampton SO14 7AY.

THE IMPORTANCE OF FINANCIAL ADVICE

• This application contains technical and legal terms with which you may not be familiar. You should therefore complete it with the help of your financial adviser.

Please answer the following question. Failure to do so will delay your application.

Have you been given advice about this application by your financial adviser?!Yes No

– E P 5

Member’s name

Contact number

E-mail address

Permanent residential address(Please note that c/o addresses are not acceptable)

Postcode

1 YOUR PERSONAL DETAILS

2 MAKING A SINGLE CONTRIBUTION

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† All cheques must be made payable to ReAssure Life Limited. If payments are being paid by a third party by cheque, please complete the third party payer details in section E.

* The net contribution must be based on current basic rate income tax applicable to the year in which the contribution is received. This net amount may vary in future, if basic rate income tax is altered.

** All employer’s contributions are payable gross. Where employer’s contributions are being made, or where your employer is acting as a co-ordinator for the payment of contributions, your employer must complete section H.

Employer**

Personal – including third-partypayments other than those fromyour employer* (payable net of basic rate income tax)

Total

Minimum single contribution contributions – £500 gross.

£ .

£ .

Gross

Complete this section if you are making a single contribution to your plan

Single contribution

£ .

£ .

** All employer’s contributions are payable gross. Where employer’s contributions are being made, or where your employer is acting as a co-ordinator for the payment of contributions, your employer must complete section H and the following Direct Debit Mandate.

= All cheques must be made payable to ReAssure Life Limited. If yearly payments are being paid by a third party by cheque, please complete the third party payer details in section E.== The first regular contribution will normally be collected within 10 days of acceptance of your application. Subsequent payments will normally be collected on the first working

day of each month.

How will the first regular contribution be paid?

Frequency of regular contributions YearlyMonthly

Cheque= Direct debit==

Employer**

Personal – including third-partypayments other than those fromyour employer*

Total

Minimum £100 gross each month, £1,000 gross each year. If you wish to amend the amount of your regular contribution please enter the total amount you wish to pay each month/year.

Total regular contribution

Gross

If you are paying regular contributions for the first time, do you wish any regular contributionsyou have chosen to be increased automatically at each annual review?Please note, the increase in contributions will normally be the greater of 10% or the rate of inflation.

Yes No

The regular contribution start date or the start date for the amended regular contribution will be the first of the month following receipt of the application for direct debit payments. If you require contributions to commence in a later month, please specify the date you require. Please note that the date cannot be backdated.

I require regular contributions to commence or be amended from 0 1 2 0

We will collect all regular contributions using one direct debit instruction. If you are an employee and your employer is paying any part of the contributions, the direct debit must be drawn on your employer’s bank account. Your employer will be responsible for collecting your personal contributions.Please note: If this is the first contribution to the policy (other than transfer payments), the first pension input period will automatically end on the first 5 April which follows payment of the first contribution.

3 STARTING OR AMENDING REGULAR CONTRIBUTIONS

£ .

£ .

£ .

£ .

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• Amended regular contributions If your fund choice for the amended contribution is the same as your current regular contribution fund choice, tick here* Now go to section E

OR Complete the table below to select different fund(s) for your amended contributions

• Single/New regular contributions

Complete the table below to select fund(s) for your single/regular contributions

4 FUND CHOICE

• If your fund choice is incomplete or otherwise invalid, we will allocate part or all of the investment as appropriate to the OMW Deposit Fund.

• We are not authorised to provide advice; your financial adviser will be able to help you choose the funds most suitable for you.

• You can choose up to 99 funds – if there is insufficient space for you to list all of your chosen funds below, continue on a separate sheet and attach it to this application.

• Any Portfolio Rebalancing currently in place will be cancelled as a result of this application; we will need a new Portfolio Rebalancing instruction if you want this service to continue.

NOTE

Please state your fund choice below.

Fund manager Full fund name

100%Total

Whole %(minimum 1% in each fund)

5 PAYMENTS TO YOUR FINANCIAL ADVISER

You do not need to complete section 5 if: you HAVE NOT been given advice about this application by your financial adviser, go to section 6.If you do not complete this section:• Any existing commission payments from your plan to your financial adviser will continue. • Any existing fund-based fee on your plan will stop.• No commission will be paid from your plan for this transaction.

Otherwise complete the section below, if you want to authorise fees for your financial adviser.

5A GUIDANCE NOTES

Your plan WILL REMAIN on Adviser Charging.

Ongoing fees:To confirm any ongoing fees complete section 5B.

YESNO

IS YOUR EXISTING PLAN ON AN ADVISER CHARGING BASIS?

HAVE YOU RECEIVED ADVICE FROM YOUR FINANCIAL ADVISER FOR THIS TRANSACTION?

IF YOU ARE NOT SUREPlease speak to your financial adviser or call our Customer Contact

Centre on 0808 171 2600 and we’ll be happy to confirm.

YESNO

DO YOU WANT TO CONTINUE TO PAY COMMISSION TO YOUR FINANCIAL ADVISER FROM YOUR PLAN?

Your plan WILL NOT CONVERT on Adviser Charging when you submit this application.

Commission:Any existing commission will continue to be paid.

Ongoing fees:Any existing fund based fee will be removed

Your plan WILL CONVERT on Adviser Charging when you complete section 6 and submit this application.

Commission:Any existing commission will stop.

Ongoing fees:To confirm any ongoing fees complete section 5B.

NOYES

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5B FEES PAYABLE FOR TRANSACTIONS WITH FINANCIAL ADVICE

Fund-based fee• The fund-based fee selected will be applied to the plan as a whole and is levied by the ongoing deduction of units from the plan.

• Any existing commission payments from your plan to your financial adviser will stop.

• If you are on Adviser Charging and you select 0% or do not enter a %, no fees will be paid to your financial adviser and any existing fees will be removed from your plan.

• Once your plan converts to Adviser Charging, this cannot be reversed.

Please note that ReAssure does not facilitate the payment of fees to financial advisers for plans opened in their own names. Financial advisers should refer to our Terms of Business with them for further information.

NOTE

Ongoing feesIf your plan is on or you would like to convert your plan to an Adviser Charging basis., tick here:

Select the fund-based fee that you have agreed with your financial adviser, if required: of the plan value each year. %

You must complete this section.Any omission or misstatement of a material fact in this application form could affect the payment of benefits under the arrangements comprising the Executive Pension. A material fact is one which is likely to influence the assessment and acceptance of this 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.

DeclarationI request that the changes detailed in this application are made to my existing plan.

a) I declare that to the best of my knowledge and belief the statements made in this application and declaration and any related documents are correct and complete and that I have not concealed any material fact.

b) I agree to supply information relevant to the Executive Pension as shall be required by ReAssure from time to time.

c) I declare that the total contributions paid by me or on my behalf to any registered pension scheme do not exceed my relevant UK earnings for this tax year.

d) I declare that contributions made to the Plan have not been and will not be funded from a tax-free cash sum from a registered pension scheme to the extent that neither myself nor ReAssure will suffer a tax liability.

e) I authorise my employer to deduct any personal contributions from my salary.

f) I confirm that the specified changes should occur from the date I have chosen and where contributions are being collected by direct debit, the new contributions should be collected, if applicable.

g) If Portfolio Rebalancing applies to my plan, I understand that:

i) my instructions will automatically be cancelled as a result of this application.

ii) a new set of Portfolio Rebalancing instructions will be required should I wish to reinstate the instructions.

Personal information

I confirm that I have read ReAssure’s privacy notice concerning use of my personal data, available at www.reassure.co.uk/privacy-notice.

Adviser Charging declaration, only if section 6 has been completed

I authorise ReAssure to deduct any fee(s) detailed in section 6 from my plan and pay them to my financial adviser.

(a) I understand that:

(i) the fee agreed will be met by deduction of units from the investments in my pension

(ii) the amount of the agreed fee is assumed to include VAT (at the rate prevailing when the fee is due), if applicable.

(b) I confirm that:

(i) I have completed and agreed this section with my financial adviser

(ii) my financial adviser has explained the effect that selling units from my pension will have on its future value

(iii) any fees agreed under Adviser Charging on this application are solely in relation to advice and/or services I have received or will be receiving on this plan only and do not relate to any other advice or services provided.

(c) I understand that:

(i) I can amend the Fund Based Fee by giving at least 10 working days notice before it is deducted

(ii) I cannot cancel a fee once it has been deducted from my plan, instead I would need to contact my financial adviser to discuss whether a refund is payable in full or in part.

6 DECLARATION AND APPLICATION

Date

Signature of applicant

2 0

Employer’s declarationThe statements in this form are correct to the best of our knowledge and belief.

Signed for and on behalf of the Employer

Capacity(Authorised Official)

Employer’s name

Date 2 0

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www.reassure.co.uk

ReAssure Life Limited, Registered Office: Windsor House, Telford Centre, Telford, Shropshire, TF3 4NB.

Registered in England No. 1363932.

Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

Firm reference number 110462.

RE0176/220-0176/March 2020

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Where the payer is not the policyholder or their employer, please provide the full name, date of birth, address and telephone number of the payer. The payer’s personal information may be made available to a third party by electronic or other means for the purpose of verifying identity in accordance with Money Laundering Regulations.In some circumstances the policyholder may be the only person permitted to pay contributions. Please contact ReAssure if you have any queries with this.

Full forename(s)

Address

Surname

Telephone number Postcode

Date of birth

Please complete the form and send to: ReAssure Life Limited, Old Mutual House, Portland Terrace, Southampton SO14 7AY. Name and full postal address of bank/building society Reference

B

Name(s) of accountholder(s)

Bank/building society account number

Branch sort code

To: The Manager

bank/building society

Address

Postcode

9 9 5 3 0 1

Service user number

- -

Instruction to your bank or building societyPlease pay ReAssure Life Limited Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with ReAssure Life Limited and, if so, details will be passed electronically to my bank/building society.

Signature(s) Date

/ /

/ /

INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY BY DIRECT DEBIT.

This Guarantee should be detached and retained by the payer.

Banks and building societies may not accept Direct Debit Instructions for some types of account.

This is not part of the instruction to your bank or building society and must be detached by ReAssure Life Limited before submission to the paying bank.

The Direct Debit Guarantee.• This Guarantee is offered by all banks and building societies that accept Instructions to pay Direct Debits.

• If there are any changes to the amount, date or frequency of your Direct Debit ReAssure Life Limited will notify you five working days in advance of your account being debited or as otherwise agreed. If you request ReAssure Life Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request.

• If an error is made in the payment of your Direct Debit, by ReAssure Life Limited or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society.

– If you receive a refund you are not entitled to, you must pay it back when ReAssure Life Limited asks you to.

• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

If your regular contributions are not paid by you or your employer, please complete the payer details below.

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ReAssure Old Mutual House Portland Terrace Southampton SO14 7AY T: 0808 171 2600

www.reassure.co.uk

ReAssure Life Limited, Registered Office: Windsor House, Telford Centre, Telford, Shropshire, TF3 4NB.

Registered in England No. 1363932.

Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

Firm reference number 110462.

RE0176/220-0176/March 2020

ReAssure Old Mutual House Portland Terrace Southampton SO14 7AY T: 0808 171 2600

www.reassure.co.uk

ReAssure Life Limited, Registered Office: Windsor House, Telford Centre, Telford, Shropshire, TF3 4NB.

Registered in England No. 1363932.

Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

Firm reference number 110462.

RE0176/220-0176/March 2020

ReAssure Old Mutual House Portland Terrace Southampton SO14 7AY T: 0808 171 2600

www.reassure.co.uk

ReAssure Life Limited, Registered Office: Windsor House, Telford Centre, Telford, Shropshire, TF3 4NB.

Registered in England No. 1363932.

Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

Firm reference number 110462.

RE0176/220-0176/March 2020