Zenith - Aviva · • the Zenith Principal Brochure • the Fund Prices leaflet Specimen policy...

Application Form

Zenith

Financial Adviser Details

Company name

Friends Provident International Agency number

Contact details for acknowledgement/queries on the application:

Contact name

Phone number

Email address

Policy Number

Policy number if known

Please contact Friends Provident International Limited (Friends Provident International) to obtain a pre-allocated

policy number if desired.

Please tick to confirm you have included with this application:

Verification of client identity*

Verification of client address*

Source of wealth (including supporting documents, where required*)

*suitably certified as being a true copy

Details of information required for Source of Wealth can be found on pages 6, 7 and 8.

XIM7/A 07.14

Failure to disclose relevant information may delay the processing of your application

2

This Form is not applicable to persons resident in Hong Kong.

This Form should be read in conjunction with the current edition of the following documents:

• theZenithPrincipalBrochure

• theFundPricesleaflet

SpecimenpolicyconditionsareavailablefromFriendsProvidentInternationalonrequest.

Please complete all details in Section 1

Pleaseprovideallrelevantinformationanddocumentationsothatwecanprocessyourapplicationassoonaspossible.Furtherinformation

mayberequiredduringthevalidationprocess(i.e.questionsarisingfromtheinformationprovided).

IfyoumakeanymistakeswhilecompletingthisForm,pleasecrossouttheerrorandwritethenewinformationasclearlyaspossible.

Each correction must be initialled by the person or persons completing the form.DoNOTusecorrectionfluidorotherwaysof

deletingincorrectinformation.

Additional information / Special instructions

Please let us know in the space below of any additional information we need to be aware of relating to the application.

XIM7/A 07.14

Section1:DetailsofApplicant(s) *Deleteasappropriate

3

To be completed by each investor who is the current legal owner of the premium(s).

Please refer to ‘What you need to provide’ for requirements to support verification of identity and address on page 18.

PleasewriteinINKanduseBLOCKCAPITALS

First (or only) Applicant

Second Applicant

1 Title

Mr

Mrs

Miss

Mr

Mrs

Miss

Other(pleasespecify)

Other(pleasespecify)

2 Surname

3 Firstname(s)

4 Marital status

5 Dateofbirth(DD/MM/YY) | | | | | |

6 Pleasetelluswhereyouwereborn.

Town

Country

Countrycode(ifknown)

7 Pleaselistallcountriesinwhichyouaretaxresident.Pleaseprovideyourtaxidentificationnumberforeachcountry.

(i) Country


Taxidentificationnumber

(ii) Country



(iii) Country



Ifnecessary,pleasesupplyanyadditionalinformationattheend.

Ifyouareunsureofyourstatusasataxresident,yourtaxidentificationnumber,oryouhaveanyothertaxqueries,westronglyrecommendyouseekprofessionaltaxguidanceinordertoavoiddelayingyourapplication.

8 Countryofresidence

9 Residence address

10 Telephone number

11 Emailaddress(mandatory)


4 XIM7/A 07.14

First (or only) Applicant

Second Applicant

12 How long have you lived at this address?

13 Correspondenceaddress(ifdifferenttoresidenceaddress)

14 Correspondenceaddressphonenumber

15 Youwillreceiveallcorrespondenceandstatementsrelatingtoyourpolicy,unlessyouindicateotherwisebelow.Copieswillalsobesentyourfinancialadviser.

Alternatively,pleasetickhereifyouwouldpreferustosendallcorrespondenceandstatementsrelatingtoyourpolicytoyourfinancialadviseronly.

16 Inwhichcountriesdoyouhavenationality/citizenshipstatus?Ifyouhavemorethanonenationality/citizenshipstatuspleasesetoutall

countriesofwhichyouareanational/citizen,aswellastherelevanttaxidentificationnumber(s)whereapplicable.

(i) Country



(ii) Country



(iii) Country



17 Occupation

(Ifretired,pleasestateformeroccupation) (Ifretired,pleasestateformeroccupation)

18 Natureofbusiness

19 Areyouingoodhealth?

Yes

No

Yes

No

IfNo,pleasegivedetailsbelow

20 AreyoutobeaPolicyholder?

Yes

No

Yes

No

21 AreyoutobeaLifeAssured?

Yes

No

Yes

No

IftheapplicantsarenottobetheLivesAssured,thesupplementaryapplicationform‘AdditionalLivesAssured/Policyholders’mustbecompleted.TheremustbeatleastoneLifeAssuredforeachpolicy.

5XIM7/A 07.14

Section2:Investmentdetails *Deleteasappropriate

Total Premium

USD/GBP/EUR/HKD* MinimumUSD15,000;GBP10,000;EUR15,000;HKD120,000

Plan Currency

Pleaseselectthecurrencyinwhichyouwishyourplantobedenominated.(Ifnoselectionismade,theplancurrencywillbethecurrencyin

whichthepremiumhasbeenpaid.)

USDollars(USD)

Sterling(GBP)

Euro(EUR)

HKDollars(HKD)

Optional Withdrawals

Investorsmaychoosetoreceivearegularincomefromtheirpolicy.ThecurrentminimumindividualwithdrawalisUSD750(orGBP500,

EUR750,HKD6,000).ThelevelofwithdrawalsmaybevariedorstoppedaltogetherbygivingwrittennoticetoFriendsProvident

InternationalLimited.

Iwishtoreceiveatotalyearlyamountof

USD/GBP/EUR/HKD*

or %

ofmyinitialinvestment,payablein

yearly

half-yearly

quarterly

monthly

termly instalments

commencing

(dateatwhichpaymentistobedispatchedfromtheCompany)

IrequestFriendsProvidentInternationaltopaythebenefitsbyTelegraphicTransfer.Pleasetransferthebenefitsintomyaccount(mustbe

policyholder’saccount).

Sortcode(ifapplicable)* | | |

SWIFT/BICcode(ifapplicable)*

IBAN(ifapplicable)*

Accountnumber

Accountname

Bank(nameandaddress)

Bank

Postcode(ifapplicable)

6 XIM7/A 07.14

Section2:Investmentdetails(continued) *Deleteasappropriate

Source of wealth

PleaserefertotheSourceofwealthtablewhichisavailableonourwebsiteorfromyourfinancialadviser,fortheevidentialrequirementsto

supportSourceofwealth.

Income and savings from salary (basic and/or bonus)

Ifself-employedoracompanyshareowner,pleasereferto‘Companyprofits’following.

Currentannualsalary Currency Amount

Employer’sname

Employer’saddress

Natureofbusiness

Maturity or encashment of life policy Amountreceived Currency Amount

Policyprovider

Policynumber/reference

Dateofmaturityorencashment

Sale of shares or other investments/liquidation of investment portfolio

Descriptionofshares/units/deposits(i.e.name/whereheld)

Nameofseller

Lengthoftimeheld Years Months

Sale amount Currency Amount

Datefundsreceived

Sale of property Sold property address

Dateofsale

Total sale amount Currency Amount

Company sale Companyname

Natureofbusiness

Dateofsale

Total sale amount Currency Amount

Client’s share %

7XIM7/A 07.14

Section2:Investmentdetails(continued) *Deleteasappropriate

InheritanceNameofdeceased

Dateofdeath

Relationship to applicant

Datereceived

Total amount Currency Amount

Solicitor’sname

Solicitor’sfirm’sname

Solicitor’saddress

Divorce settlement Datefundsreceived

Total amount received Currency Amount

Nameofdivorcedpartner

Company profits Companyname

Companyaddress

Natureofcompany

Amountofannualprofit Currency Amount

Asset (share) exchange Originandmeansofwealth

Gift Datefundsreceived

Pleaseprovideallofthefollowing:

• Letterfromdonorexplainingthereason for the gift and the source ofdonor’swealth

• Certifiedidentificationdocumentsfor donor

Total amount Currency Amount

Relationship to applicant

Donor’ssourceofwealth


8 XIM7/A 07.14

Section2:Investmentdetails(continued)

Employer paying policy Countryofincorporation

Pleaseprovidethefollowing:

• Employer letterIncorporationnumber

Retirement income Retirement date

Previousoccupation

Nameoflast(final)employer

Addressoflast(final)employer

Pensionincomesource

Fixed deposit – savingsNameofinstitutionwheresavingsheld

Dateaccountestablished

Detailsofhowsavingsacquired

Dividend Payment Dateofreceiptofdividend

Total amount received Currency Amount

NameofCompanypayingdividend

LengthoftimetheshareshavebeenheldintheCompany Years Months

Other source of wealthPleaseprovideasmuchdetailaspossible.


9XIM7/A 07.14


9

Choice of Funds

Pleaseindicatethefundsinwhichyouwishyourplantoinvest,uptoamaximumof10,showingthepercentageoftheinvestiblepremium

youwishtobeinvestedineachfund.Thetotalpercentagemustaddupto100%(pleasenotewecanonlyacceptwholepercentages).

Failure to include all relevant information accurately may delay the processing of your application.

Fund Code Fund % of Premium

Total 100%

XIM7/A 07.1410


Source of Payment

Option 1Use this option if you are paying by personal cheque or if you wish Friends Provident International Limited to collect the premium

from your bank on your behalf.

Please tick the appropriate box and follow the instructions carefully.

BY PERSONAL CHEQUE. PleasemakechequespayabletoFriendsProvidentInternationalLimited.

BY TELEGRAPHIC TRANSFER. PleasecompletetheappropriateBank Instruction Letter atthebackofthisFormandreturnittoFriendsProvidentInternationalLimitedwiththisApplicationForm.

Option 2Use this option if you are making your own arrangements for payment by Banker’s Draft or Telegraphic Transfer.

Please tick the appropriate boxes and complete the Source of Payment section below.

BY BANKER’S DRAFT. IhavearrangedforthepremiumtobepaidbyBanker’sDraft,asindicatedbelow,payabletoFriendsProvidentInternationalLimited(Ref:Policyholder).IhaveforwardedacertifiedcopyoftheBankAcknowledgementLettertoFriendsProvidentInternationalLimitedwiththisDraft.Please tick one box only

USDollarDraft,drawnonabankinNewYork

SterlingDraft,drawnonabankintheUnitedKingdom

EuroDraft,drawnonabankintheEuropeanEconomicandMonetaryUnion(EMU)

HKDollarDraft,drawnonabankinHongKong

BY TELEGRAPHIC TRANSFER. IhavearrangedforthepremiumtobepaidbyTelegraphicTransfer(Ref:Pre-AllocatedPlan

Number,ifknown:_______________________________)andIhaveforwardedacertifiedcopyoftheBankApplicationFormto

FriendsProvidentInternationalLimited.

I confirm the Banker’s Draft/Telegraphic Transfer is to be paid for by debit of funds from my personal bank account. The details of

this account are:Sortcode(ifapplicable)* | | |

SWIFT/BICcode(ifapplicable)*

IBAN(ifapplicable)

Accountnumber

Accountcurrency

Accountname

Bank(nameandaddress)

Bank


Payment Methods

XIM7/A 07.14 11

Section3:Declarations

Important Notes

1 Aspecimenpolicydocumentand/orcopyofthiscompletedformareavailableonrequest.

2 Youareadvisedtosatisfyyourself/selvesthat,underanytaxation,exchangecontrolorinsurancelegislationtowhichyoumaybesubject,youarepermittedtoeffectthepolicy.

3 Youshouldseekguidancefromyourusualfinancialadviserastothesuitabilityofthepolicytoyourownparticularcircumstances.

4 InformationwhichyouprovideinconnectionwiththisApplicationandanysubsequentPolicywillbeheld(whetherstoredelectronicallyorotherwise),usedordisclosedbyFriendsProvidentInternationaloranyassociatedcompanythatexistsfromtimetotime.Youhavetherighttoobtainaccesstoandtorequestacorrectionofanypersonalinformationaboutyou.RequestscanbemadetotheDataProtectionOfficeratRoyalCourt,Castletown,IsleofMan,BritishIslesIM91RA.

5 EachpolicyisgovernedbyandshallbeconstruedinaccordancewiththelawsoftheIsleofMan.

6 UnderlyingfundprospectusesareavailablefromFriendsProvidentInternationalonrequest.

7 SPECIALISTFUNDACKNOWLEDGEMENT

Weofferproductsthatprovideaccesstoawiderangeoffunds,knownasmirrorfunds,thatinvestinallthemajorassetclassesandgeographicregionsoftheword.Someofthesemirrorfundsinvestintofundswhichareclassedasspecialistfunds,aimedatprofessionalorexperiencedinvestors.Ifyouweretoinvestintosuchafunddirectly,asaseparateventurenotlinkedtothisApplicationandinsteadofusingoneofourmirrorfunds,youmayhavetodeclarethat:

• Youhavereadandunderstoodtheinformationsuppliestoyouandunderstandthenatureofanyrisksinvolved.

• Youhavediscussedwithyourfinancialadviserwhethersuchanassetisappropriatetoyourinvestmentportfolio.

• Youareeligibleandabletoinvestintothefundandhavethelevelofinvestmentknowledgeandexperiencerequiredbythefundmanager.

• Youmeetcertainminimumfinancialrequirements.

Ordinarilysomeofthesefundscouldonlybeheldbyprofessional/experiencedinvestorsratherthanretailinvestors.Also,informationrelatingtosuchinvestmentsmaynotbeavailablefordistributionincertainjurisdictions.However,whentheinvestmentismadethroughyourpolicy,wearetreatedastheprofessionalorexperiencedinvestorandthisenablespolicyholdersthatmaynothavebeenabletodoso,toaccessthesefunds.

Pleasenotethatdifferentjurisdictionsmayimposedifferentcriteriaonthegenerallyaccepteddefinitionofaprofessional/experiencedinvestor.Fulldefinitions,restrictionsandinvestorrequirementscanbefoundineachfund’sprospectus/termsandconditions,whichisavailablefromthefundmanageroryourfinancialadviser.Werecommendthatyouobtain,readandfullyunderstandacopyoftheprospectus/termsandconditionsforyourchoseninvestment.

Professional Investor Funds

AProfessionalInvestorFund(‘PIF’)isavailableonlytoprofessionalinvestorswhoaregenerallymarketprofessionals.OfteninvestorsarerequiredtohaveanetworthrequirementthatistypicallyinexcessofUSD1million.ThetypicalminimuminvestmentinaProfessionalInvestorFundisUSD100,000.Therearelimitedregulationscoveringformalcontentoffundliteratureanddocuments.Itisnotsubjecttoanyregulatoryrestrictionsonitsinvestmentandborrowingpowers.TheOfferingDocumentmustcontainsufficientinformationtoenableaninformedinvestmentdecisionandmustcontainriskwarnings.

Liquidity Information

Someofourfundsmayhaverestrictionontheirabilitytopayredemptionsduetothetypeofunderlyinginvestmenttheyhold.Thiscouldlimityourabilitytoraisecashfromthefundinthefuture.

Investinginfundsshouldbeconsideredalong-terminvestment.Youinconjunctionwithyourfinancialadviser,shouldconsidertheamountyouinvestviayourpolicyifitislikelythatyouwillneedaccesstoyourcapitalquicklyinthefuture.


12XIM7/A 07.14

Declarations

AttentionisdrawntothefollowingDeclarations.IftheApplicationformrequestsinformationwhichhastobeassessedbytheCompanybeforeacceptance,thenyoumustdiscloseallfactswhicharematerial.Suchfactsarethosewhichaninsurerwouldregardaslikelytoinfluencetheassessmentandacceptanceofaproposal.Ifyouareindoubtastotherelevanceofanyparticularinformationyoushoulddiscloseit,asfailuretodosocouldresultinyoubeingquotedthewrongterms,aclaimbeingrejectedorreduced,orthepolicybeinginvalid.

1 FUNDACKNOWLEDGEMENT Beforeyouinvestinanyspecialistfundsthroughyourpolicy,FriendsProvidentInternationalwishestoensurethatyouareawareofthenatureandpossiblerisksassociatedwiththem.Wouldyouthereforepleasemakethefollowingdeclarations:

(i) IunderstandthatImaychoosetheinvestmenttowhichmypolicyistobelinked.

(ii) Iacknowledgethatitismyresponsibilitytoensurethatthefundissuitablebearinginmindmyinvestmentobjectivesandattitudetorisk.

(iii)IconfirmthatIunderstandcertainfundsmayhaverestrictionsontheirabilitytoraisecashinthefuture,andthatfurtherdetailsareincludedintheprospectustermsandconditions.fortherespectiveunderlyinginvestment.Iunderstandtherisksassociatedwithinvestingthesefunds.

(iv)IfIchoosetoinvestintomirrorfundswhichinturninvestintospecialistfundsaimedatprofessionalinvestors,Iacknowledgethatitismyresponsibilitytoobtain,readandunderstandtheunderlyingfund’sprospectus.

(v) IacknowledgethatFriendsProvidentInternationalisnotresponsiblefortheinvestmentperformanceoranylosssufferedorreductioninthevalueofmypolicyarisingfrommyinvestment.FriendsProvidentInternationaldoesnothaveanyresponsibilityfortheinvestmentmanagementoftheunderlyingfundandFriendsProvidentInternationaldoesnotapproveanyassetasasuitableinvestment.

(vi)IacknowledgethatthepurchaseofmyinvestmentsmaybedelayedifFriendsProvidentInternationalrequiresasigneddeclarationinrespectofmychoseninvestments.

(vii)Iacknowledgethespecificinvestorprotectionandcompensationschemethatmayexistinrelationtocollectiveinvestmentsanddepositaccountsareunlikelytoapplyintheeventoffailureofsuchaninvestmentheldwithininsurancepolicies.

2 GENERALDECLARATIONS

IdeclarethatthisApplicationwassignedin (country)

and the advice was given in(country)

IfurtherdeclarethatalltheinformationprovidedinthisApplicationForm,includingthisDeclaration,arecompleteandtrue,tothebestofmyknowledgeandbelief,alltheabovestatementsaretrue.Iagreethatthey,togetherwithanyotherstatementsmadetoamedicalexaminerintheeventofamedicalexaminationortotheCompany,noworinthefuture,shallformthebasisofthepolicyunderthelawsoftheIsleofMan.IhavereadandunderstoodalltheprintedmaterialsrelevanttothispolicyandIhaveacquaintedmyselfwiththemanagementchargesmadebyFriendsProvidentInternational.

IfurtherdeclarethatIunderstandandagreethatthepolicyshallnotbecomeeffectiveuntilitisissuedwiththefirstpremiumpaidinfullandallrequirementshavebeenmet.

IunderstandthatthisApplicationcanonlybeacceptedbyemployeesofFriendsProvidentInternationalLimitedsituatedattheCompany’sHeadOfficeintheIsleofManandthatnootheremployeesorthirdpartieshavethenecessaryauthoritytocreateabindingcontract.

Iamawarethatdeliberatetaxevasionisacriminaloffence.IamresponsibleformyowntaxaffairsandIherebydeclarethatIunderstandmypersonaltaxobligationsandresponsibilitiesandIhavecompliedwithalllegalrequirementstomakedeclarationstotaxauthoritiesandpaythetaxthatIowe.AsappropriateandnecessaryIhavetaken,orwilltake,legaladviceinrelationtomytaxaffairsandinparticular,mytaxobligationsastheyapplytothisApplication.

3 CANCELLATIONRIGHTS IfyouareresidentintheUK,orhavesignedthisApplicationformintheUK,youwillbeabletocancelyourinvestmentduringa30day

periodafterconcludingtheagreement.Youwillreceivearefundofpremiumlessadeductionforshortfalltoreflectanyfallinthemarketsintheinterim.Youwillbetoldofthisrightinmoredetail,includingwhenitbeginsorendsandhowtoexerciseit,indocumentsthatwewillsendyouattherelevanttime.


13XIM7/A 07.14

4 DATAPROTECTION IagreethatanypersonalinformationcollectedorheldbyFriendsProvidentInternational(whethercontainedinthisApplicationor

otherwise)isprovidedandmaybeheld,usedordisclosedbyFriendsProvidentInternationalandtransferredbetweenitsofficesandothermembersoftheFriendsLifegroupofcompanieswherevertheyaresituated.IunderstandthatFriendsProvidentInternationalandothermembersoftheFriendsLifegroupwill:

(i) useandtransfertheinformationtoprofessionaladvisers,ITserviceproviders,financialadvisers,mailinghouses,agents,underwritersandreinsurersforthepurposesofadministration,underwriting,claims,researchorstatisticalpurposes.Suchprocessingissubjecttocontractualrestrictionsandappropriatesecuritystepstoprotecttheinformation;

(ii) communicatewithme,myindependentfinancialadviserandfundadviserwhetherdirectlyorindirectlyforanypurpose;and

(iii) tosupplythedetailsorprovideacopyoftheinformationtoanyfinancialservicescompanywherevertheyaresituatedtoenablethepurchaseofassetsrequestedtobelinkedtothepolicy;

(iv) transferinformationtomirrorregulatorybodiesorauthorities,forexampletheInsuranceandPensionsAuthority,theUnitedArabEmiratesInsuranceAuthority,theUSInternalRevenueServiceandothertaxauthoritiestoenablethemtocarryouttheirregulatoryandstatutoryfunctions;and

(v) discloseinformationtothirdpartiesinordertocomplywithanti-moneylaunderinglawsandforotherpurposessuchasthepreventionofcrimeordetectionoffraud,enablingassetstoberightfullyclaimedorwhererequiredbylaworregulation.

BysigningthisformIconsenttothisuseofmypersonaldata.

IunderstandthatFriendsProvidentInternationalwouldliketokeepmeinformedaboutotherproductsandservicesprovidedbycompanieswithintheFriendsLifegroupandothercarefullyselectedorganisations.

Idonotwishyoutocontactmeby: First(oronly)Applicant SecondApplicant

Post Phone Email Post Phone Email

YoumaychangeyourmindatanytimebywritingtotheDataProtectionOfficer,RoyalCourt,Castletown,IsleofMan,BritishIsles,IM91RA.Otherwisewewillassumethatyouarehappytobecontactedinthiswayuntilinstructedotherwise.

5 WITHHOLDINGTAX/PREMIUMTAX

Iacknowledgethatintheeventofanypremiumtaxorwithholdingtaxbeingleviedinmy/ourcountryofresidenceitwillbethemyresponsibilitytoincreasethepremiumbyanamountequaltotheliabilityortosettletheliabilitydirectlywiththerelevanttaxauthorities.

6 IacknowledgethatFriendsProvidentInternationalandmyfinancialadviserhaveenteredintoanagreement(‘termsofbusiness’)whichsetsoutthebasisuponwhichFriendsProvidentInternationalispreparedtoacceptApplicationssubmittedbythefinancialadviseronmybehalf.Thisagreementcategoricallystatesthatthefinancialadviseractsasmyagent,andnottheagentofFriendsProvidentInternational.

Iacknowledgethatmyfinancialadviser,oranyother,hasnoauthoritytoactastheagentofFriendsProvidentInternationalortostate,

suggestorimplythatithassuchauthority.IacknowledgeandauthorisemyfinancialadvisertoberemuneratedforitsservicesbybrokeragecommissionfromFriendsProvidentInternational.

Signature(s) First (or only) Applicant Second Applicant

Signature Signature

Date Date

14 XIM7/A 07.14


15XIM7/A 07.14

BankInstructionLetter(non-FarEastterritories) *Deleteasappropriate

Please note that some banks insist that their own Bank Instruction form is used, so you should check with your bank that they will accept this document.

ThislettershouldbereturnedwithyourApplicationForm.

PleaseuseBLOCKCAPITALS.

NameandfullpostaladdressofyourBank

To:TheManager Bank

Address


AccountNumber SortCode(ifapplicable)

|

|

|AccountCurrency(mustbecompletediftheaccountismulti-currency) SWIFT/BICCode(ifapplicable)

AccountHolder’sName IBAN(ifapplicable)

Section A – Telegraphic Transfers

DearSir,

OnmybehalfwouldyoupleaseprepareaTelegraphicTransferandcarryoutthetransactionindicatedwithin48hoursofyoureceivingthis

instruction.

IfremittingSterlingfromaUK/ChannelIslandorIsleofManbankaccount,sendthepaymentbyCHAPSdirecttotheIsleofManBank

Limited,EastRegion,Douglas,SortCode60-95-45.Forallothercurrencies,pleaseremitaSWIFTPaymentOrderdirecttoIsleofManBank

Limited,SWIFTCodeRBOSIMD2,IBAN:GB48RBOS60954540038485.ThebeneficiaryaccountnameisFriends Provident International

Limited andthebeneficiaryaccountnumberisshownbelow.

Sterling,USDollarandEuroTransfer–AccountNo.9545-40038485

Thereferencenumberbelow(seeSectionB)mustbequotedbytheBankonalladvices.

GBP/USD/EUR/Other* (figures)

GBP/USD/EUR/Other* (words)

Pleasechargetheamountofthepaymenttogether with any bank and agent bank’s charges tomyaccount.

Yoursfaithfully,

Signature(s) Signature

Date

Signature

Date

MyAddress

Section B (tobecompletedbyFriendsProvidentInternationalLimited)

ThisReferenceNumbermustbequotedbytheBankonalladvices(tobecompletedbyFriendsProvidentInternationalLimited).


16 XIM7/A 07.1416

XIM7/A 07.14


17

Applicable to Applicants with bank accounts in the Far East.

Please note that some banks insist that their own Bank Instruction form is used, so you should check with your bank that they will accept this document.

ThislettershouldbereturnedwithyourApplicationForm.

PleaseuseBLOCKCAPITALS.

NameandfullpostaladdressofyourBank

To:TheManager Bank

Address


AccountNumber SortCode(ifapplicable)

|

|

|AccountCurrency(mustbecompletediftheaccountismulti-currency) SWIFT/BICCode(ifapplicable)

AccountHolder’sName IBAN(ifapplicable)

Section A – Telegraphic Transfers

DearSir,

OnmybehalfwouldyoupleaseprepareaTelegraphicTransferandcarryoutthetransactionindicatedwithin48hoursofyoureceivingthis

instruction.

PleaseremittoHSBCLimited,1Queen’sRoad,Central,POBox64,HongKong,SWIFT CodeHSBCHKHH,forcredittoFriends Provident

International Limited andthebeneficiaryaccountnumbershownbelow.

USDollarTransfer–AccountNo.511-667685-201

SterlingTransfer–AccountNo.511-667685-202

EuroTransfer–AccountNo.511-667685-220.

HKDollarTransfer–AccountNo.511-667685-001

Thereferencenumberbelow(seeSectionB)mustbequotedbytheBankonalladvices.

USD/GBP/EUR/HKD* (figures)

USD/GBP/EUR/HKD* (words)

Pleasechargetheamountofthepaymenttogether with any bank and agent bank’s charges tomyaccount.

Yoursfaithfully,

Signature(s) Signature

Date

Signature

Date

MyAddress

Section B

ThisReferenceNumbermustbequotedbytheBankonalladvices(tobecompletedbyFriendsProvidentInternationalLimited)

BankInstructionLetter(FarEastbankaccountsonly) *Deleteasappropriate

What you need to provide

Step 3 Authentification of documents by a suitable certifier (for each Applicant)

18 XIM7/A 07.1418

What you need to provideVerification of identity and address

We have a legal obligation to verify the identity and residential address of each person who will apply for one of our

products.Wealsohavearegulatoryobligationtoobtaindetailsofhowtheapplicant(s)has/haveacquiredthemonies/

assetsthattheywillinvestwithus.

Therearegoodreasonsfordoingthis.Criminalsandterroristsoftentrytolaundermoneybyusingfalseorstolen

identitiesinordertoopenaccountsorplaceinvestmentswithfinancialinstitutionssuchasFriendsProvidentInternational

Limited.Byprovidingtheinformationanddocumentsrequested,youarenotonlyhelpingtheCompanytocomplywith

stringentmoneylaunderinglegislation,butyouarehelpingtoprotectyourownidentity.

Therequireddocumentstoverifyidentityare:

• APassport;or

• AGovernment-issuedIdentityCard(carryingaphotographoftheindividual).

WhereitisnotpossibletoobtaineitheraPassportoraNationalIdentityCard,twootherformalgovernment-issued

documentscarryingappropriatepersonaldetails,whichshowverifiablereferencenumbers,maybeaccepted.Examples

would include:

• DrivingLicensewithphotograph

• AnnualTaxAssessmentissuedbytheTaxAuthorities

• AGovernment-issueddocumentcontainingauniquereferencenumberwhichisspecifictoeachApplicant.

Thesedocumentsmustbecertified(pleaserefertoSTEP3).

Step 1Verify the identity of each Applicant

Step 2Verify the address of each Applicant

Wewillalsorequireanoriginalorcertifiedcopyofadocument,toverifyeachApplicant’sresidentialaddress(pleaserefer

to STEP3).Alistofthedocumentsthatareacceptableforthispurposeisprovidedbelow.

ThedocumentmustbeissuedinthenameoftheApplicantandshowtheresidentialaddressthatappearsonthe

applicationform.Inallcasesthedocumentsseenshouldbethemostrecentavailable,andnoolderthan3months,unless

thedocumentusedtoverifyaddressisonlyissuedonanannualbasis.

• UtilityBill,(water,Gas,electricity,landlinetelephoneconnection)RatesInvoice,counciltaxnotification

Please note, mobile telephone bills, cable TV bills and Internet service provider’s bills are not acceptable as

evidence of address

• Currentdrivinglicensewithphotograph

• Taxassessmentdocument

• ExtractfromtheofficialRegistrarofElectors

• BankAccountstatement

Please note, statements of credit cards and non-bank cards, such as store cards, are not acceptable

• Statepension,benefitorothergovernment-produceddocumentshowingbenefitentitlements

• LetterfromtheApplicant’semployer,confirmingtheirresidentialaddressandthepolicyholder’spositionwithinthe

company.WheretheApplicanthasaccompaniedapartnerorspouseonaworkassignmentorcontract,andthey

arealsoanApplicant,anemployermayconfirmtheaddressofanon-employeewherearelationshipisdetailed.If

theapplicant(orspouse)istheowner/partownerofthecompanyaletterfromthecompanywillnotbeaccepted.

• Proofofownershiporrentaloftheresidentialaddress

• Mortgagestatement.

Thesedocumentsmustbecertified(pleaserefertoSTEP3).

XIM7/A 07.14

What you need to provide19

Step 4Step 3Authenticationofdocumentsbyasuitablecertifier(foreachApplicant)

Background

Incorrectcertificationofdocumentsisoneofthemainreasonsfordelaysinprocessingapplications.TheIsleofMan

InsuranceandPensionsAuthority,ourprincipalregulator,isveryspecificabouthowdocumentsaretobecertified,and

whocanperformthisfunction.

Certificationofcopydocuments

The certifier must state on the document:

‘I certify that this is a complete and accurate copy of the original documentation that I have seen...’

Signed: (the signature of the certifier)

Name: (the printed name of the certifier)

Position/Capacity: (the position or capacity of the certifier)

Date: (the date of certification)

Impropercertificationcouldleadtodelays.

Ifthedocumentismorethanonepage,thecertifiercaneither:

• certifyeachpageindividuallyor,

• certifythetoppageandaddastatementdetailingthenumberofpagesoftheoriginaldocumentationseen.

Who can certify a copy of an original document?

The adviser you have appointed

Who has recommended this product to you

A notary public, licensed lawyer or solicitor

Anotarypublicisapublicofficerappointedunderauthorityofstatelawwithpowertoadministeroaths,certifyaffidavits,

takeacknowledgementsandtakedepositionsortestimony.

An authorised representative of an embassy or consulate ofthecountrythatissuedtheidentificationdocuments.

Translation of documents not written in English

WhereadocumentsubmittedforaddressverificationisnotwritteninEnglish,werequirethecertifiertoexplainonthe

document:

• What the document is

• Indicatewheretheapplicant’snameandaddressisprinted

• The certifier should also write a statement onto the document to the effect that:

‘I certify that the address stated on this document is a true translation of the English address written on the

application form…’

Signed: (the signature of the certifier)

Name: (the printed name of the certifier)

Position/Capacity : (the position or capacity of the certifier)

Date: (the date of certification)

What you need to provide20 XIM7/A 07.14

Step 4 Source of wealth

Background

IsleofManauthorisedlifecompaniesarerequiredbytheInsuranceandPensionsAuthoritytomakeenquiriesastohow

aclientapplyingforoneofourproductshasacquiredthemoniesthatwillbeinvested.ThisSourceofwealthinformation

isanintegralpartoftheoverall‘KnowYourClient’(KYC)requirementsthatwemustperform.Itisalsoalegal,aswell

asaregulatoryrequirement,toperformarisk-basedassessmentoftheapplicantandconductenhancedduediligence

wherehigherriskcircumstancesareidentified.Thismeansthatincertaincircumstancesindependentevidencewill

berequiredtosupporttheexplanationoftheclient’sSourceofwealth.Incorrectcertificationofdocumentsisoneof

themainreasonsfordelaysinprocessingapplications.TheIsleofManInsuranceandPensionsAuthority,ourprincipal

regulator,isveryspecificabouthowdocumentsaretobecertified,andwhocanperformthisfunction.

Information to be provided

Onpages6,7and8ofthisapplicationform,youshouldclearlyexplainhowyouhaveacquiredthewealththatyouwill

usetopaypremiums.

Supporting documentation to evidence Source of wealth

FriendsProvidentInternationalusesboththepremiumsizeandyourresidentiallocationtoidentifywhenapplications

requiredocumentaryevidence.Evidencewillberequiredwherethepremiumisonorabovethelimits.

Premiumlevelsandcountryriskratingsaresubjecttoalterationandforthatreasonyouwillneedtorefertothepremium

limitstablepublishedonthecompany’swebsite.ItisavailableinPDFformatonourwebsite.

Youwillneedtocombinethepremiumlevelsindicatedinthepremiumlimitstablewiththeriskratingofyourcountryof

residence(orcountrywherewealthisgenerated),todeterminewhetherevidentialsupportshouldbesubmittedwiththis

application.Weneeddocumentaryevidenceeachtimeapremiummovesthetotalcumulativepremiumon,orhigher,

thanthepremiumlimitsallocatedtotheparticularcountryrisk.Yourfinancialadviser,whohasrecommendedthisproduct

toyou,willbeabletohelpandadviseyouwiththis.

Important note to the introducing intermediary: ALL COPIES of original documentation must be properly certified by

you,theintroducingintermediary,inthesamemannerasyouwouldcertifyclientidentitydocumentationandresidential

addressproof.

Trust applications

Wherethepaymentismadebythetrustees,thesamesourceofwealthinformationasaboveshouldbeprovidedforthe

settlorandsettledmonies.

21XIM7/A 07.14

Notes

22 XIM7/A 07.14

Notes

23 XIM7/A 07.14

Important InformationThe information given in this document is based on Friends

ProvidentInternationalLimited’sunderstandingofcurrentIsleof

Manlawandtaxationpractice,whichmaychangeinthefuture.No

liabilitycanbeacceptedforanypersonaltaxconsequencesofthis

schemeorfortheeffectoffuturetaxorlegislativechanges.

Investmentinvolvesrisk.Pastperformanceshouldnotbeviewedas

areliableguideoffutureperformance.Fundpricesmaygoupand

downdependinguponunderlyinginvestmentperformance,andthe

valueofyourinvestmentcannotbeguaranteed.Investmentsheld

within a fund may not be denominated in the currency of that fund

and the value of those assets can go up and down simply because

ofmovementsincurrencyexchangerates.Allfundperformance

quotedisnetofannualcharges.Youmaygetbacklessthanyou

paidin.

Prospectiveinvestorsshouldconsultwiththeirfinancialadviser

beforeenteringintoapolicyofthisnature.

The product is intended for medium to long-term investment and is

notthereforedesignedforearlycash-in.Anearlycash-inchargemay

beapplied.

AllpolicyholdersareprotectedbytheLifeAssurance(Compensation

ofPolicyholders)Regulation1991oftheIsleofMan,wherevertheir

placeofresidence.

Investorsshouldbeawarethatspecificinvestorprotectionand

compensationschemesthatmayexistinrelationtocollective

investmentsanddepositsaccountsareunlikelytoapplyintheevent

offailureofsuchaninvestmentheldwithininsurancecontracts.

ComplaintswecannotsettlecanbereferredtotheFinancial

ServicesOmbudsmanSchemefortheIsleofMan.

SometelephonecommunicationswiththeCompanyarerecorded

andmayberandomlymonitoredorinterrupted.

EachPolicyisgovernedbyandshallbeconstruedinaccordance

withthelawsoftheIsleofMan.However,thiswillnotprecludethe

righttobringlegalactioninaHongKongcourt.Ifyoueffectapolicy

whilstresidentintheUnitedArabEmirates,alldisputesregarding

thepolicyshallbesubjecttothenon-exclusivejurisdictionofthe

courtsoftheUnitedArabEmirates.

Copyright©2014FriendsProvidentInternationalLimited.

Allrightsreserved.

XIM7/A07.14(43766)

Friends Provident International Limited

Registered & Head Office: Royal Court, Castletown, Isle of Man, British Isles, IM9 1RA Telephone: +44(0) 1624 821212 Fax: +44(0) 1624 824405Website: www.fpinternational.com

Incorporated company limited by shares Registered in the Isle of Man No. 11494Authorised by the Isle of Man Insurance & Pensions AuthorityProvider of life assurance and investment products

Authorised by the Office of the Commissioner of Insurance to conduct long-term insurance business in Hong Kong

Registered in the United Arab Emirates as an insurance company (Registration No.76) and as a foreign company (Registration No. 2013)Authorised by the United Arab Emirates Insurance Authority to conduct life insurance and savings business

Registered in Singapore No. F06835GRegistered by the Monetary Authority of Singapore to conduct life insurance business in Singapore

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