1 of 4

INTERMEDIARY REGISTRATION FORM

This registration applies to the following Providers:− Old Mutual Wealth Life Assurance Limited− Old Mutual Wealth Limited− Old Mutual Wealth Life & Pensions Limited

You must attach a sheet of your firm’s letterhead to this form.

Please tick/complete this form using BLOCK CAPITALS only and blue or black ink.

1. Name of firm

2. Trading name u If different from above

3. Address

Postcode

4. Contact details

5. Type of firm u Please tick (3)

6. Full names of managing director, directors, partners or principal

Telephone number

Fax number

Email address

Limited company Registered number

Sole trader Partnership Limited Liability Partnership

continued

A INTERMEDIARY DETAILS

Website

2 of 4

7. Have the directors, partners or principal been associated with an intermediary which has registered to place business with any of the Provider companies?

No

Yes u Please give details. Continue on a separate sheet if necessary

8. Has a registration ever been refused to your firm by an insurance, assurance or investment company or society?

No

Yes u Please give details. Continue on a separate sheet if necessary

9. Do you belong to a Service Provider/Are you an Associate Member of a Network?

14. Indemnity/Non-indemnity

Indemnity terms are included in the Terms of Business (attached) u Old Mutual Wealth Life Assurance Limited only

No

Yes u Please give details and attach a copy of your Confirmation of Membership where this is available

10. Enter your firm’s Financial Services registration number

Indemnity Non-indemnity

Other u Please specifyMonthly Fortnightly Weekly15. Frequency of commission payments

16. Details of your firm’s bank account

Account number

Bank name

Sort code

− −

Postcode

Bank address

Direct credit payments will normally be cleared into your account three working days after the commission statement.

Account name

A INTERMEDIARY DETAILS (continued)

B COMMISSION DETAILS

C PAYMENT DETAILS

PDF0479/219-0585/May 2019 (Intermediary registration)

11. Do you use any lead generators or introducer firms?

No

Yes u Please list their full company name and FCA number

12. Is your business model:

Advised

Non-Advised

A mixture u Please estimate what percentage of your firm’s business is non-advised

13. Was your firm known by any other names in the past?

No

Yes u Please give details

3 of 4

Master user and deputy master userThe master user is the person responsible for specifying those individuals within your company who can have access to Old Mutual Wealth’s technology platform. In a large company, this could be your systems administrator, in a smaller company it could be a senior office administrator, the principal or their PA.

The master user shall be responsible for the day-to-day monitoring and safekeeping of passwords and usernames.

A deputy master user may be appointed to assist the master user in executing these responsibilities, and/or to assume these responsibilities in the absence of the master user.

Other u Please specifyMr Mrs MissTitle

Full forename(s)

Surname

Position in company

Email address

Please choose a username u Minimum of 5 and maximum of 8 characters

Master user

YOU DO NOT NEED TO COMPLETE THIS SECTION IF YOU WILL BE SOLELY DOING PROTECTION BUSINESS WITH US.

Telephone number

Fax number u If different from company fax number

Correspondence address u If different from company address

Other u Please specifyMr Mrs MissTitle

Full forename(s)

Surname

Position in company

Email address

Deputy master user

Telephone number

Fax number u If different from company fax number

Correspondence address u If different from company address

D ACCESS TO OLD MUTUAL WEALTH’S TECHNOLOGY PLATFORM

Postcode

Postcode

PDF0479/219-0585/May 2019 (Intermediary registration)

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 Life Assurance Company Limited, Old Mutual Wealth Limited and Old Mutual Wealth Life & Pensions Limited are registered in England & Wales under numbers 1363932, 1680071, and 4163431 respectively. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom.

Old Mutual Wealth Life Assurance Company Limited and Old Mutual Wealth Life & Pensions Limited are authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Their Financial Services register numbers are 110462 and 207977 respectively.

Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority with register number 165359. VAT number for all above companies, except Old Mutual Wealth Life Assurance Limited, is 386 1301 59.

PDF0479/219-0585/May 2019 (Intermediary registration)

Declaration – to be signed by all the directors, all the partners or the principal.

I/We acknowledge receipt of the Terms of Business and confirm acceptance of them.

I/We declare that the statements made in this form are true and complete. I/We apply to place business with the Providers in accordance with the Terms of Business. I/We authorise the Providers to obtain any references they may require.

Signature u Director/Partner/Principal*

Signature u Director/Partner/Principal*

Signature u Director/Partner/Principal*

Note:For a limited company with more than one director or a partnership, we will accept the signature of only one director or partner on the understanding that the director or partner is signing for and has the authority of all directors or partners of the company or partnership.

*delete as applicable

E DECLARATION

Date (ddmmyyyy)

2 0

Date (ddmmyyyy)

2 0

Date (ddmmyyyy)

2 0

Send the completed form to:

Old Mutual Wealth FAO Broker Administration Old Mutual HousePortland TerraceSouthamptonSO14 7AY

E-mail: ask@omwealth.com

4 of 4