Please use BLOCK CAPITALS and blue or black ink. Please tick boxes as appropriate.If you need more space than is provided to answer any questions, please continue on a separate sheet of paper.All references to Old Mutual Wealth in this questionnaire mean Old Mutual Wealth Life Assurance Limited.

NOTES. If the sum assured exceeds £3,500,000 for life cover or £2,000,000 for critical illness cover: 1. For shareholder/partnership protection please provide 3 years accounts/reports or investment prospectus.2. For keyperson cover, please provide 3 years accounts or reports and evidence of earnings (P60 or payslip).3. For keyperson investor protection, please provide a copy of the investor prospectus with confirmation of investment made.4. For loan cover please provide a copy of the loan offer or latest loan statement.

Full name of life assured

Plan/application reference number

Please give details of existing cover and any proposed with other companies (ie amount and reason for cover − single/joint life first death/joint life last death/personal/keyman).

Proposed sum £assured

prIvaTE aNd cONfIdENTIalfINaNcIal quESTIONNaIrEFOr ShArehOLder/PArTnerShIP, Key PerSOn And BuSIneSS LOAn COver

a dETaIlS Of ThE lIfE aSSurEd

lIfE aSSurEd

continued

Amount £

reason for cover

do you have any existing or proposed life cover? (3) noyes

Joint life firstSingle life Joint life last

Will the cover be cancelled? (3) noyes

1 of 6

2 of 6

5. What was the turnover and profit or loss for the last three years?

Turnover

Gross profit/(loss)

net profit/(loss)

2 0 2 0 2 0

1. Full name of the company or partnership.

2. how long has it been in existence?

4. What is the total number of employees?

3. What is the exact nature of the business?

B quESTIONS rElaTINg TO ThE cOmpaNy Or parTNErShIp

a dETaIlS Of ThE lIfE/lIvES aSSurEd (CONTINUED)

do you have any existing or proposed critical illness cover? (3)

lIfE aSSurEd

Amount £

reason for cover

noyes

Will the cover be cancelled? (3) noyes

3 of 6

c quESTIONS rElaTINg TO ThE lIfE aSSurEd (parTNErShIp/SharEhOldEr)

1. What has been his/her salary and/or share of profits in each of the last two years?

Salary

Share of profits

Who made the valuation?

2. What is the percentage of the total shareholding? %

3. What value has been placed on the business? £

2 0 2 0

4. Is there a double option or buy/sell agreement or is one to be executed in the near future? (3) noyes

how was this calculated?

If not, please confirm reasons.

5. do all other directors/shareholders/partners have existing cover or current applications for cover? (3) noyes

4 of 6

5. Please give details of all other key people with existing cover or current applications for cover.

4. What percentage of profits are attributed to the key person and why?

2. What salary and other remuneration has been paid in each of the last two years?

Salary

Other remuneration

2 0 2 0

1. Why is the life assured classified as a key person (copy of service agreement or Cv can be provided)?

3. how was the sum assured calculated (if loan related please complete loan cover section)?

d quESTIONS rElaTINg TO ThE kEy pErSON (lIfE aSSurEd)

5 of 6

1. Loan amount £

2. duration of loan

If ‘yes’, please state why.

4. What is the purpose of the loan?

3. Are the amount and term of the policy different from those of the loan? (3)

5. Who is the lender?

6. Start date of the loan

E quESTIONS rElaTINg TO ThE lOaN cOvEr

noyes

7. Is the policy a condition of the loan agreement? (3) noyes

d d M M y y y y

name

Position of signatory

I/We declare that to the best of my/our knowledge and belief, these statements are true and complete and that I/we agree this supplementary proposal

and the proposal dated shall form the basis of the contract between me/us and Old Mutual Wealth.

Signed

date

f dEclaraTION

d d M M y y y y

d d M M y y y y

I understand that:• Youmayprovidemydata,byelectronicorothermeans,to:

– other companies within the Old Mutual Wealth and Old Mutual groups of companies if you regard this as necessary to service my plan– my adviser– my employer– a third party to verify my identity in line with money laundering or other requirements which may involve carrying out checks with credit reference databases– third parties who perform tasks for you to help you service my plan. These third parties may be based in countries outside the eeA. I understand that

these countries may not have laws to protect my data equivalent to those of the uK. however, I understand that you will ensure that any such thirdparties agree to treat my data with the same level of protection as if you were dealing with it.

• Topreventanddetectfraudyoumay:– share my data with other organisations, including the police– check and/or file my data with fraud prevention agencies and databases, and if I give you false or inaccurate information and you suspect fraud, you

will record this.• YouandothercompanieswithintheOldMutualWealthandOldMutualgroupsofcompaniesmayusemydataforassessmentandstatisticalanalysis

purposes.• Mydatamaybemadeavailabletothirdpartieswhererequiredbylaw,courtorderorregulation.• Onpaymentofasmallfee,IamentitledtoreceiveacopyofmydatawhichissubjecttotheDataProtectionAct1998.• Ialsohavetherighttorequireyoutocorrectanyinaccuraciesinmydata.InsuchcircumstancesIcancontactyouatOldMutualWealthLifeAssurance

Limited, Old Mutual house, Portland Terrace, Southampton, SO14 7Ay.

Old mutual Wealth head Office PO Box 37 Old Mutual house Portland Terrace Southampton SO14 7Ay T:02380334411 f:02380220464

www.oldmutualwealth.co.ukCalls may be monitored and recorded for training purposes and to avoid misunderstandings.

OldMutualWealthLifeAssuranceLimitedisregisteredinEngland&Walesundernumber1363932.RegisteredOfficeatOldMutualHouse,Portland Terrace, Southampton SO14 7eJ, united Kingdom. Authorised by the Prudential regulation Authority and regulated by the Financial Conduct AuthorityandthePrudentialRegulationAuthority.FinancialServicesregisternumber110462.VATnumber386130159.

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