DiscounteD Gift trust - Old Mutual Wealth · Page 1 of 12 DiscounteD Gift trust ... section 2 of this form is where you can provide this information. ... (w dGt app) Page 2 of 12

*APDBA0300F*

Page 1 of 12

DiscounteD Gift trustFor use with bare and discretionary versions

Part aAPPlicAtion For A collective investment Bond to use with A discounted GiFt trust

• THIS APPLICATION CANNOT BE SUBMITTED ONLINE

• If you wish to invest using our WealthSelect Managed Portfolio Service (MPS), the MPS declaration on page 8 must be signed by your financial adviser.

• The Capital Protected Death Benefit cannot be selected for a Discounted Gift Trust.

• Underwriting u If you send your payment at the same time as this application, we will invest it without waiting for an underwriting

decision. Please note the following: – The cancellation period on the bond is 30 days from the bond start date. Since the underwriting process often exceeds 30 days,

you will have to surrender the bond if you decide not to proceed. – No wthdrawals are permitted until the trust is declared. – The discount calculation may be based on the value of the bond where the process for underwriting exceeds 3 months. – If you would rather wait until underwriting is complete, do not send a payment yet; we will inform you of the underwriting

decision after which payment can be sent for investment, if required.

NOTE

TAX INFORMATION

Under Exchange of Information regulations we are required to obtain various details of our investors, including where they were born, their nationalities, countries of tax residence* and related tax identification numbers** - section 2 of this form is where you can provide this information. We also need to obtain `a self-certification’ that the information provided is true and complete - this is contained in the declaration in section 8.

We may have to provide this information to HMRC who may share it with overseas tax authorities. We may contact you for further information if required.

Non UK Tax – if you are subject to tax in any country outside the UK, please contact your tax specialist, to understand whether you will be liable for tax in that country.

*Country of tax residence Normally you are resident for taxation in the country in which you spend the majority of your time each year. However, some countries (eg the United States) may also treat an individual as resident for taxation based on their nationality or citizenship. As tax residence is determined by the country in which tax is paid, it is possible to be tax resident in more than one country.

**Tax identification number (TIN)If your country of tax residence is the UK or the Isle of Man your TIN is your National Insurance number. If it is Guernsey, Jersey or Gibraltar it is your Social Security Number. If you are a US national/tax resident it is your US Tax Identification Number.

• For help to work out where you are tax resident, or if you are unsure about your TIN, please consult your financial adviser or the information at www.oecd.org/tax/automatic-exchange.

• If you are unsure what information to include, please consult your financial adviser.

IMPORTANT DOCUMENTS YOU NEED TO HAVE RECEIVED BEFORE PROCEDING• You need to have received several important documents about this product and the funds you choose, before you send us your

application to invest in a CIB.• More information about these documents is in section 1.

!

FIRST APPLICANT’S DETAILS

JOINT APPLICANT DETAILS (if applicable)

Client reference number, if known

E-mail address

Surname

Full forename(s)

Correspondence address (if different from residential address)

Permanent UK residential address

Postcode

Title Mr Mrs Miss Other (please specify)

Telephone number (in case of query)

Postcode

Date of birth(dd/mm/yyyy)

nationality(ies) country(ies) of tax residence tax identification number(s) (tin) reason for no tin (if applicable)

Client reference number, if known

E-mail address

Surname

Full forename(s)

Correspondence address (if different from residential address)

Permanent UK residential address

Postcode


Contact telephone number (in case of query)

Postcode

Date of birth(dd/mm/yyyy)

town/city of birth country of birth

town/city of birth country of birth

nationality(ies) country(ies) of tax residence tax identification number(s) (tin) reason for no tin (if applicable)

Gender Male Female

Gender Male Female

PdF5435/218-0247/march 2018 (w dGt app) Page 2 of 12

We only accept business for investors who have received financial advice. This is because financial advisers can recommend investments that are most suitable for investors’ financial circumstances. Old Mutual Wealth cannot provide such advice.

Tick below as applicable

I have received financial advice in respect of this application

On what basis was the advice given? (your financial adviser will help you answer this) Restricted Independent

Your financial adviser will have provided you with the following important documents:• a Key features Document and terms & conditions for the collective investment Bond• a Key information Document (KiD) about the collective investment Bond • information, including rebates, about the funds chosen for your investment In section 8, the declaration you sign will include your confirmation that you have received and read these documents. Key Investor Information Documents (KIIDs) or Key Information Documents (KIDs) are also produced by fund managers and provide important information about their funds. We strongly recommend reading these documents to assist you in making an informed investment decision.

1 FINANCIAL ADVICE

Please tick/complete this form, as applicable, using BLOCK CAPITALS and blue or black ink.u�Complete the form carefully; errors or omissions by you or your financial adviser will not be corrected retrospectively

2 YOUR DETAILS

First life assured

Second life assured (if applicable)

Third life assured (if applicable)

CIB investment amount £

please enclose cheque payable to Old Mutual Wealth Life & Pensions Limited

Select payment method

(minimum £10,000)

Cheque number

Electronic bank transfer (in favour of Old Mutual Wealth Life & Pensions Limited)To: Natwest. Sort code 56-00-68. Account number 37632116. In the reference field on your bank transfer please enter your postcode and surname to help us process your application.

3 LIFE/LIVES ASSURED

4 INVESTMENT DETAILS

Surname

Surname

Surname

Full forename(s)

Full forename(s)

Full forename(s)

Date of birth(dd mm yyyy)



Relationship to the applicant






Gender Male Female

Gender Male Female

Gender Male Female

•Theapplicantsnamedinsection2(referredtointhetrustdeedasthe‘settlors’)ortheirspouses/civilpartners**mayNOTbeincludedas lives assured. This is because under the Finance Act 1986, Paragraph 7, Schedule 20, a gift with reservation may consequently arise.

NOTE

u please provide the same information for any additional lives assured by using a copy(ies) of this page.

•Ifyousendyourpaymentatthesametimeasthisapplication,wewillinvestitwithout waiting for an underwriting decision.

•Ifyouwouldratherwaituntilunderwritingiscomplete,do not send a payment yet; we will inform you of the underwriting decision after which payment can be sent for investment, if required.

NOTE


a tick one of the following to indicate which investment range your fund choice is from, then list the funds below:

Wealthselect – to invest using our wealthselect managed Portfolio service (mPs), state the name of the managed Portfolio below and ask your adviser to sign the mPs

declaration on page 8

selfselect

Investment %Unit/Share type ie Inc/Acc†

† if no unit/share type (ie inc/Acc) is stated, accumulation units (where available) will automatically be applied. where accumulation units have been selected and they are not available, income units will be automatically applied or vice versa. For more information on income and accumulation units/shares, refer to our Funds list.

An investment choice continuation sheet is available on request.1totaL 0 0

Bundled funds u SelfSelect only

where both ‘bundled’ funds (full Annual management charge (Amc) with rebates) and ‘unbundled’ funds (lower Amc with reduced rebates) are available, we will automatically default to unbundled funds.

Tick here if you wish us to use the bundled version of the funds selected (where available)

full name of fund or portfoliou the funds must all be from the same investment range, not a mixture from both

B PhaseD investment u not available in conjunction with automatic rebalancing

c automatic reBaLancinG u not available in conjunction with Phased Investment

Phase every month for:

Automatically rebalance every:

starting on:

starting on:

3 months

3 months

6 months

6 months

12 months

12 months

5 funD choice

%

if the fund choice you give is missing, illegible or otherwise invalid, we will place the investment into the Blackrock cash Fund, after which you or your adviser can switch* into a revised fund choice.* Remember: if you have automatic rebalancing on your bond, switches will cause it to be cancelled and you will need to provide us with a new

rebalancing instruction for it to continue.

NOTE

• We can place your investment into the BlackRock Cash Fund then phase it into your selected fund choice on the first working day of each month over 3, 6 or 12 months. to request phased investment, complete the required frequency and start date below:

• We can automatically rebalance your CIB back to your selected fund choice and proportions on the 15th of the month every 3, 6 or 12 months. To request automatic rebalancing complete the required frequency and start date below:

• Phased investment instructions will apply to all BlackRock Cash Fund holdings within your CIB, not just the investment in this application. • You cannot phase back into the BlackRock Cash Fund.• If you do not specify a start date, phasing will begin in the next available month following your application.

If you do not specify a start date, rebalancing will begin on the next available date for the frequency selected.

0 1 2 0

1 5 2 0

complete part a, then B or c if required


Please read this section carefully before signing and dating the declaration. this declaration is made by each applicant.

1. i wish to apply for a collective investment Bond as indicated in this form.

a) i apply to invest in 1,000 unit-linked, whole of life assurance policies referred to collectively as the collective investment Bond.

b) i declare that:

– i am 18 years of age or over

– i am resident in the united Kingdom and will inform old mutual wealth life & Pensions limited if this changes in the future.

c) I understand that Old Mutual Wealth Life & Pensions Limited will administer the bond in accordance with UK tax legislation.

2. i authorise old mutual wealth life & Pensions limited:

a) to hold interest distributions, dividends and any other rights or proceeds in respect of my investments in the collective investment Bond, and

b) to sell units or shares in investments within my bond to meet any charges or fees for my financial adviser, in accordance with the terms and conditions; and

c) to give effect to my instructions in accordance with the terms and conditions.

(continued)

8 DecLaration anD siGnature(s)

we will sell units as follows to meet the Product charge. the same funds will be used to meet any Adviser servicing Fees the trustees subsequently agree to pay (if applicable).

7 Payment of the ProDuct charGe

initial fee for lump sum

complete this section if you wish us to deduct an initial fee for your financial adviser from your bond.

Switch and servicing fees cannot be authorised until the trust is declared.

fund switch fee and servicing fee

• Percentage fees must be entered in multiples of 0.05%.

• Initial fees are deducted prior to investment. The 5% tax deferred allowance on the bond should therefore be calculated using the net investment amount.

NOTE

£ %orinitial fee required: from your lump sum payment

• Once the trust has been declared, the trustees may wish to pay the financial adviser switch fees and/or servicing fees.

• These fees will need to be authorised on our Ongoing Adviser Fee Authorisation Form, available from your financial adviser or by contacting us.

• All the trustees will need to sign the form to authorise deduction of these fees.

• Any adviser fees paid from your bond will count towards your 5% annual withdrawal allowance and may, therefore, have tax implications.

NOTE

• the deductions will be made proportionally across all the life policies in your bond.

• more information about the Product charge is in the document ‘making the cost of investment clear (charge Basis 3)’.

• If you do not specify a preference, we will deduct the payments from the largest fund in your bond.

NOTE


6 Payments to your financiaL aDviser

Managed Portfolio Service (MPS) investors – we will sell units proportionally from all of your funds.

Other investors – choose one of the following options:

ORLargest fund The following fund(s)Proportionally from all funds OR

3. i understand that i will not receive confirmation relating to transactions involving the purchase or sale of investments which are carried out on a periodic basis in the manner agreed to in this application. details of these transactions will be shown in the periodic statement which will be sent to me. in particular, such transactions include:

– phased investments

– automatic rebalances

– automatic withdrawals

– dividend and rebate reinvestments

– sales of units to meet old mutual wealth life & Pensions limited charges and fees for my financial adviser (if applicable).

4. i have been given the opportunity to read and keep the following, and to have any questions concerning them answered to my satisfaction:

a) terms and conditions, to which i agree

b) Key Features document

c) Key information document about the collective investment Bond

d) information including rebates, in respect of my chosen funds.

5. i consent to my personal data being used in accordance with the Personal data statement in the terms and conditions.

6. i declare that this application has been completed correctly and to the best of my knowledge and belief.

7. i confirm that i have obtained the consent of each life assured to use of their personal data in accordance with the Personal data statement contained within the terms and conditions and am signing the application as his/her agent(s) as well.

8. if i have completed section 6 of this form:

a) i authorise old mutual wealth to deduct any fee detailed in section 6 from my investment and pay it to my financial adviser.

b) i understand that any initial fee agreed will be met by deduction from my payment before the balance is invested into my choice of funds

c) i confirm that:

i) i have completed and agreed section 6 with my financial adviser

ii) my financial adviser has explained the effect that selling units to pay Adviser Charges from my investment will have on its future value.

d) i understand that i cannot cancel a fee once it has been deducted, instead i would need to contact my financial adviser to discuss whether a refund is payable.

e) i confirm that old mutual wealth has brought to my attention the importance of reading and discussing section 6 of this form with my financial adviser, before signing below.

9. tax information – I understand that for regulatory purposes Old Mutual Wealth is required to obtain information concerning my taxation status.

a) i declare that:

i) I am resident for taxation in the country(ies) shown in section 2 of this application and I am not resident for taxation elsewhere.

ii) i am a national of the country(ies) shown in section 2 of this application and i am not a national or a citizen of any other country.

iii) i will inform old mutual wealth if this changes in the future.

iv) the information in section 2 and the statements made in this declaration are correct and complete, to the best of my knowledge and belief.

b) i understand that:

i) Old Mutual Wealth may need to contact me for further information regarding tax information

ii) if I am resident for taxation outside of the UK, Old Mutual Wealth may need to share my information with the relevant tax authorities.

*APDBA0300X*

8 DecLaration anD siGnature(s) continueD

Applicant 1

Applicant 2 (if applicable)

date

date

2 0

2 0

Signatures u all applicants must sign


www.oldmutualwealth.co.uk

Please be aware that calls and electronic communications may be recorded for monitoring, regulatory and training purposes and records are available for at least five years.

old mutual wealth is the trading name of old mutual wealth limited which provides an individual savings Account (isA) and collective investment Account (ciA) and old mutual wealth life & Pensions limited which provides a collective retirement Account (crA) and collective investment Bond (ciB).

old mutual wealth limited and old mutual wealth life & Pensions limited are registered in england and wales under numbers 1680071 and 4163431 respectively. registered office at old mutual house, Portland terrace, southampton so14 7eJ, united Kingdom. old mutual wealth limited is authorised and regulated by the Financial conduct Authority. old mutual wealth life & Pensions limited is authorised by the Prudential regulation Authority and regulated by the Financial conduct Authority and the Prudential regulation Authority. their Financial services register numbers are 165359 and 207977 respectively. vAt number 386 1301 59.

Full name of regulated firm (or sole trader)

1. I understand that adviser fees will be paid subject to the limits outlined in Old Mutual Wealth’s Remuneration Guide.2. i confirm that: (a) i have verified the identity of all relevant parties referred to in this application (b) the information in this form was obtained by me in respect of the relevant parties (c) the evidence i have obtained to verify the identity of the relevant parties can be produced on demand and meets the standard of evidence set out

within the guidance for the uK Financial sector issued by the Joint money laundering steering Group (JmlsG) (d) if any individual referred to in this application has changed address within the last three months, i can provide evidence on demand (e) I have not verified the identity of the following parties referred to in this application because they are exempt from verification under Money

laundering regulations

(f) this section is signed below by the person who has seen the documentary evidence (which may include an electronic identity check).

3. Tax information Based on the knowledge I have gained of the relevant parties, I have no reason to believe that the tax residency self-certification in section 8 of this

form (point 9) requires any follow-up action from me.

Financial adviser’s signature*

Financial services number

date (dd/mm/yyyy)

Print name

contact number

Position

9 financiaL aDviser’s DecLaration u to be completed by your financial adviser

2 0

Send the completed form to:

Old Mutual WealthOld Mutual HousePortland TerraceSouthamptonSO14 7AY

Tel: Customer Contact Centre 0808 171 2626

checKList

once you have signed the application, please check that you have completed all applicable sections and enclosed the following:

signed cheque, if applicable, for the amount shown in section 4

Part B – health declaration

Part c – Authorisation to obtain a General Practitioner’s report

managed Portfolio service (mPs) Declaration, to be signed by your financial adviser, only if the mPs is required


* if the applicant wants to invest using our managed Portfolio service, you must also sign the declaration on page 8.

Declaration relating to OLD MUTUAL WEALTH’S MANAGED PORTFOLIO SERVICETHIS DECLARATION MUST BE SIGNED BY THE FINANCIAL ADVISER ONLY IF THE APPLICANT WANTS TO INVEST USING OUR MANAGED PORTFOLIO SERVICE (MPS).

1. I have read and agree to the following WealthSelect Managed Portfolio Service declaration.

2. I confirm that I have explained the Managed Portfolio Service to my client(s) and I request on their behalf that you invest their CIB into the Managed Portfolio I have selected.

3. I confirm that for each client:

a. I have given advice in relation to the suitability of using the Managed Portfolio Service and to the Managed Portfolio to be selected which meets my client’s needs.

b. I have provided the client with the factsheet for the relevant Managed Portfolio; I have given the client an opportunity to read it and they understand the investment risks relating to the Managed Portfolio Service in general and specifically to the relevant Managed Portfolio.

c. I am responsible for ensuring that the Managed Portfolio selected is suitable currently and on an ongoing basis in accordance with my duties under the FCA rules.

d. My client is aware that you, as the portfolio manager, will have complete discretion over the assets in each Managed Portfolio to buy, sell, retain, exchange or otherwise deal in assets, take all routine and day-to-day decisions about the asset allocation of the Managed Portfolios, and that the client and I are not permitted to provide such dealing instructions or modifications to the Managed Portfolio.

e. My client accepts that the agreement to provide the Managed Portfolio Service is between you and them as detailed in the Terms and Conditions, and you are offering this service to them as part of your agreement with them on the condition that I am appointed as their financial adviser to offer advice in respect of the ongoing suitability of the Managed Portfolio for their needs.

f. My client understands that where they have existing instructions to pay withdrawals or deduct the Product Charge or adviser servicing fees from specific funds, these will automatically be changed to withdrawals or deductions taken proportionally across all funds.

I have explained the potential tax implications of this change to my client and they accept these.

g. My client has a copy of the Charge Basis 3 Terms and Conditions for their investment, including details of the two investment ranges and the WealthSelect Managed Portfolio Service.

h. My client has had an opportunity to read and understand the Terms and Conditions before agreeing to the use of the Managed Portfolio Service.

For use with the Collective Investment Bond (CIB) Discounted Gift Trust

Financial adviser’s signature Financial adviser’s name (print)

Date (dd/mm/yyyy)

/ / 2 0



Old Mutual Wealth is the trading name of Old Mutual Wealth Limited which provides an Individual Savings Account (ISA) and Collective Investment Account (CIA) and Old Mutual Wealth Life & Pensions Limited which provides a Collective Retirement Account (CRA) and Collective Investment Bond (CIB).

Old Mutual Wealth Limited and Old Mutual Wealth Life & Pensions Limited are registered in England and Wales under numbers 1680071 and 4163431 respectively. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Old Mutual Wealth Life & Pensions Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Their Financial Services register numbers are 165359 and 207977 respectively. VAT number 386 1301 59.


2. do you suffer from or have you ever undergone treatment, investigations or operations for the following illnesses and conditions? – heart disease, disorder or surgery – stroke or tiA (transient ischaemic Attack) – diabetes – cancer, hodgkin’s disease, lymphoma or leukaemia – dementia, Alzheimer’s disease or memory loss symptoms – Any neurological disorder, loss of balance or falls

Please tick/complete, as applicable, using BlocK cAPitAls and blue or black ink.

first applicanthave you ever applied for a discounted gift scheme and been advised of a zero discount?If you have ticked Yes, please give details.

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

1. Are you currently awaiting/undergoing any specialist investigations or in-patient treatment?

If you have ticked Yes, please give details.

if so please state the condition, details of the treatment and the dates.

If Yes, please give details.

3. Are you able to live independently?

4. do you receive regular care assistance?

(continued)

this declaration must be completed by the applicant(s) for the collective investment Bond. the underwriting decision will be based on your answers And further medical information we may request from your GP or other medical specialist.

*APDBC0200F*

6. do you smoke cigarettes, or have you in the last 12 months?

if so what is your daily consumption?

5. Please confirm your height and weight

m ft ins kg st lbsor or

height Weight

DiscounteD Gift trustFor use with bare and discretionary versionsPart BheAlth declArAtion

Yes no

Yes no

Yes no

Yes no

Yes no

Yes no


Joint applicant (if applicable)

have you ever applied for a discounted gift scheme and been advised of a zero discount?If you have ticked Yes, please give details.

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

1. Are you currently awaiting/undergoing any specialist investigations or in-patient treatment?

If you have ticked Yes, please give details.

6. do you smoke cigarettes, or have you in the last 12 months?

if so what is your daily consumption?

2. do you suffer from or have you ever undergone treatment, investigations or operations for the following illnesses and conditions? – heart disease, disorder or surgery – stroke or tiA (transient ischaemic Attack) – diabetes – cancer, hodgkin’s disease, lymphoma or leukaemia – dementia, Alzheimer’s disease or memory loss symptoms – Any neurological disorder, loss of balance or falls

if so please state the condition, details of the treatment and the dates.

If Yes, please give details.

3. Are you able to live independently?

4. do you receive regular care assistance?

5. Please confirm your height and weight





Yes no

Yes no

Yes no

Yes no

Yes no

m ft ins kg st lbsor or

height Weight

Yes no


*APDBC0200F*

This form should be completed in conjunction with Parts A and B.

old mutual wealth life & Pensions limited will determine an estimated discounted value of the gift, based on information in the General Practitioner’s report. Please ensure you read sections 2, 3 and 4 overleaf before signing in section 4.

DiscounteD Gift trustPart cAuthorisAtion to oBtAin A GenerAl PrActitioner’s rePort

1 BonD aPPLicant DetaiLs

First applicant

Doctor’s details Doctor’s details

Previous doctor’s details*if registered with your current doctor for less than six months

Previous doctor’s details*if registered with your current doctor for less than six months


Full name Full name

Doctor’s full name Doctor’s full name

Previous doctor’s full name Previous doctor’s full name

Residential address Residential address

Doctor’s address Doctor’s address

Previous doctor’s address Previous doctor’s address

Postcode Postcode

Postcode Postcode

Postcode Postcode

Date of birth (dd/mm/yyyy) Date of birth (dd/mm/yyyy)

/ // /

Gender GenderMale MaleFemale Female

Telephone number Telephone number

Telephone number Telephone number






Before we can apply for a medical report from a doctor who has cared for you, we need you to give your consent by signing in section 4. Please read the information below carefully as it explains the rights of UK residents under the Access to Medical Reports 1988 and the Access to Personal Files and Medical Reports (N.I.) Order 1991. You do not have to give your consent but, if you do, you should state in section 3 whether you wish to see the report before it is sent to our chief medical officer.

If you wish to see the report, we will write to you when we ask the doctor for it and tell the doctor that you wish to see the report. You must contact the doctor to arrange to see the report within 21 days of receiving our letter. the sooner you act, the sooner we can consider your application. if you say you do not wish to see the report, we do not have to tell you if we apply for one. however, if you change your mind before such a report is sent to us, you should contact the doctor immediately, saying you wish to see it. You will have 21 days from then to see the report.

If you see a report before we do, the doctor cannot send it to us without your consent. You can write to the doctor, asking him/her to amend any part of the report which you consider to be incorrect or misleading. You can also ask the doctor to attach a statement of your views on any part of the report where you and the doctor do not agree and the doctor is not willing to alter the report.

Whatever you decide, you can still ask the doctor for a copy up to six months after it is completed. If you ask the doctor for a copy of the report, he/she can charge you a reasonable fee to cover costs.

doctors do not always have to let you see any part of a report for the following reasons:

• if the doctor thinks it would be likely to cause serious harm to your physical or mental health or that of others • if the report would indicate the doctor’s intentions towards you • if disclosure would be likely to reveal information about another person • if disclosure might reveal the identity of another person who has supplied information about you, unless that person has consented or the

information comes from a health professional involved in caring for you.

in such cases, the doctor must tell you, and you will only be able to see any remaining part of the report. if the whole report is affected, the doctor cannot send it to us without your consent.

under the Access to medical reports Act 1988 and the Access to Personal Files and medical reports (n.i.) order 1991, uK residents have certain rights regarding any medical report which we may ask a doctor to complete. Please read the details of these rights in section 2 before completing this part.

Note: If you indicate that you wish to see any medical report before it is sent to us, this may delay this application. You may prefer not to see any report at this stage and to take advantage of the right to ask your doctor for a copy up to six months after it is completed.

First applicant

i wish to see the report before it is sent to old mutual wealth life & Pensions limited

i do not wish to see the report before it is sent to old mutual wealth life & Pensions limited

this declaration is made by each applicant.

i have been informed of my statutory rights under the Access to medical reports Act 1988 and the Access to Personal Files and medical reports (n.i.) order 1991 (see sections 2 and 3). in connection with the contract applied for, i consent to old mutual wealth life & Pensions limited obtaining a medical report from any medical practitioner who has attended me in england, scotland, wales and northern ireland. i agree that a copy of this consent will have the validity of the original.

Each applicant must tick one box only; if neither is ticked, we will assume that the applicant does not wish to see the report.


2 your riGhts of access to meDicaL rePorts

3 access to rePorts

4 DecLaration

*APDBC0200X*

Applicant 1

Applicant 2 (if applicable)

date

date

D D M M 2 0 Y Y

D D M M 2 0 Y Y

Signatures u all applicants must sign
