With Profits Pension Annuity

(1)

Once we receive the fully completed application form and the cancellation period for the chosen Personal Illustration has expired, we will contact your existing arrangement(s) and arrange for the funds to be sent to us, to enable your benefits to be set up.

You can use this application form to apply for a With Profits Pension Annuity for either:-

• a transfer of benefits being made into the Liverpool Victoria (1996) Personal Pension Scheme.

Where multiple transfers of benefits are being made, you can use this form to apply for all such transfers (using sheets additional to the form where there are more than four arrangements involved). Your With Profits Pension Annuity will only be set up once all the funds being transferred have been received by us.

or

• exercising an open market option (OMO) under your existing pension arrangement.

Where you are exercising the open market option relating to a number of pension arrangements it is necessary for a

separate application form to be completed for each arrangement. Each arrangement will be set up as a separate With Profits Pension Annuity when the funds are received, although we will combine the payments if you choose to have the annuities paid on the same day of the month.

A copy of this Application form, and the Policy Conditions, are available on request.

Checklist

To assist you in completing this form we have detailed below the sections you need to complete, depending upon the type of arrangement which the funds are coming from and whether this represents the exercise of an OMO, or a transfer of benefits into Liverpool Victoria’s personal pension scheme to provide an immediate annuity. Please ensure that the appropriate sections of the form are fully completed to avoid delay in setting up the benefits.

Sections

Type of arrangement

A B C D E F G H I

*This section should be used where the omo is in respect of an Additional Voluntary Contribution from the main scheme.

For details about the Liverpool Victoria With Profits Pension Annuity, please see the ‘Key features’ document and ‘Plan guide’. Please write clearly, in block capitals, using black ink. Tick the appropriate boxes, where applicable.

If you would like help completing your application,

please talk to your Independent Financial Adviser.

Application form

With Profits

Pension Annuity

Personal Pension Scheme - OMO Occupational Pension Scheme – OMO* Free Standing Additional Voluntary Contribution (FSAVC) - OMO Buy-out Policy - OMO

Pension Transfer to immediate annuity

(2)

Section A - Annuitant’s details

Mr Mrs Miss Ms Other Forenames in full Surname Address Postcode

Telephone number (for queries) Day Evening

Male Female Date of birth

NI number

Section B - With Profits Pension Annuity details

B1 Your Personal Illustration

Please enclose a copy of the Personal Illustration you have chosen as the basis of this annuity application. If you cannot do this, please give the details requested below.

Illustration ref no Illustration date

B2 Your Annuity Start Date

On what date do you ideally want your Annuity contract to start?

B3

Amount of tax free cash you want to take (if allowed):

None Maximum Amount

B4 Anticipated bonus rate (Please tick your chosen rate)

0% 0.5% 1% 1.5% 2% 2.5% 3% 3.5% 4% 4.5%

D M Y

letters numbers numbers numbers letter

£

(3)

Liverpool Victoria With Profits Pension Annuity

Section H - Declaration

To: Liverpool Victoria Friendly Society Limited

I apply to purchase a With Profits Pension Annuity and declare and/or agree that:

a. I have read the Key Features of the With Profits Pension Annuity.

b. I will be bound by the With Profits Pension Annuity Policy Conditions.

c. I understand that you will not process this application until after the 14 day cancellation period has ended.

d. My annuity cannot start until this application has been accepted by you and all the purchase monies have been paid in full.

e. No benefits have been paid to me from the existing arrangement(s), other than tax free cash, where applicable.

f. The annuity cannot be surrendered, altered, transferred or assigned except as allowed by statute or the Rules of the scheme shown in this application.

g. To the best of my knowledge and belief the information given in this application is true and complete and I will advise you promptly in writing of any change which affects this information.

h. I agree that this application shall form the basis of the contract between us.

i. Where this application relates to a transfer of benefits into the Liverpool Victoria personal pension scheme I apply to become a member of, and agree to be bound by the Rules of, the Liverpool Victoria (1996) Personal Pension Scheme.

j. I understand that where the purchase price relates to occupation pension scheme related benefits, it may be necessary to restrict any increases generated by the policy so that the revised level of pension does not exceed the maximum permitted by the Inland Revenue.

k. You may contact the existing arrangement(s) detailed in this application to be contacted and arrange for the fund(s) to be paid to Liverpool Victoria in order that the benefits may be set up.

l. I agree to supply you with any additional information you may require for Inland Revenue or administration purposes.

m. You may ask other pension scheme providers for information about any pension schemes under which I have benefits, and I authorise the giving of this information.

n. You may use information held about me and/or supply this information to other organisations within your Group to keep my records up to date and/or for research purposes

Under Data Protection legislation you have the right of access to your personal records held by us. Copies of your completed application and the Policy Conditions are available on request.

By signing this declaration I am allowing the Society to process my application using the information that I have provided. I agree that the Society holding this information on computer, paper file or other medium for as long as the application is being

considered, for as long as the annuity remains in force and for an appropirate period thereafter.

Signed Date D M Y

Annuitant

(4)

B5

Your Annuity Payments

Please tick (one box only) to show how you want your annuity paid:

In advance In arrears In arrears with proportion without proportion

Monthly

Quarterly

Half-yearly

Yearly

B6

Guaranteed period

You can choose to have a guaranteed period for your annuity. Please indicate your choice below (whole years only – maximum 10).

No guarantee

5 year guarantee

Other period Please specify years

If the Annuity purchase is as a result of the exercise of an OMO from an occupational pension scheme, Buy-out policy or FSAVC which offers the flexible use of FSAVC benefits, and the chosen Guaranteed period does not exceed 5 years, are the remaining instalments to be commuted for a lump sum if death occurs within the Guaranteed period?

(5)

Your dependant’s details (if any, eg spouse or child)

Please give details of the person who is to receive this income. (If they die before you, no dependant’s income will be payable on your death).

Dependant’s relationship to you

If not your spouse or child, is the person named below financially dependent on you in whole or part? Yes No

Mr Mrs Miss Ms Other

Forenames in full

Surname

Address

Postcode

NI number

If the Annuity purchase is as a result of the exercise of an OMO from an occupational pension scheme, Buy-out policy or FSAVC which offers the flexible use of FSAVC benefits, and the chosen Guaranteed period is 1 to 5 years, is the

dependant’s annuity to be on a with or without overlap basis? (With overlap means that the dependant’s annuity will commence on the first due date following the death of the annuitant; without overlap means that the dependant’s annuity will commence at the end of the chosen Guaranteed period).

With overlap Without overlap

D M Y

letters numbers numbers numbers letter

B7 Dependant’s annuity

You can opt for a financial dependant to receive a percentage of your income after your death. Please tick (one box only) the amount of dependant’s income to be provided. (For transfers of benefits into the Liverpool Victoria personal pension scheme to provide an immediate annuity or Personal Pension Scheme OMO the maximum percentage is 100%; for an OMO from an occupational pension scheme, Buy-out policy or FSAVC the maximum percentage is 2/3rds)

None 50% 2/

3rds 75% 100% Or, choose your own percentage

(6)

B9 Details of the account to which annuity payments are to be paid

Annuity payments will be credited directly to the bank, building society or giro account chosen. Please give details below:

Who is to receive the payments? Net to the annuitant (Please complete details below)

Gross to the trustees (Liverpool Victoria will send you a form)

Note: if part of the pension has been ‘earmarked’ for an ex-spouse, it will be necessary for us to obtain relevant bank details to enable payments to be made. We will supply a form for completion by the ex-spouse direct to them, where appropriate.

Name of bank / building society

Address

Postcode

Name of account holder(s)

Sort code Account number

B8

If you are divorced

Has any of your pension and/or tax free cash been ‘earmarked’ for an ex-spouse? Yes No

If ‘Yes’ you must enclose the original order from the court (if there has been an amendment to this order you must also include this) and provide the following details in respect of your ex-spouse, where known:

Mr Mrs Miss Ms Other

Forename(s) in full

Surname

Address

Telephone Number (for queries) Day Evening

NI Number

% of total payment representing ex-spouse’s interest %

Note: You must inform the ex-spouse of the purchase of the annuity within 14 days from the date of purchase. It is then the ex-spouse’s responsibility to contact Liverpool Victoria to claim part of this benefit and advise current bank details.

Postcode

D M Y

(7)

Details of existing arrangement(s)

Important Note: Liverpool Victoria is unable to accept any payment which represents a

substitution for any form of State Benefits.

Section C - Open Market Option from a Personal Pension

Scheme

Full name of Scheme

Inland Revenue Approval Ref: Policy/Membership No.

Name & Address of Scheme Administrator/ Trustee

Tax free cash already taken? Yes No

Purchase Price

Section D - Open Market Option from an Occupational

Pension Scheme

(Including Additional Voluntary Contribution arrangements, where applicable)

Inland Revenue approval type: Approved (or submitted for approval under Chapter I, Part XIV of ICTA 1988)

Approved under S608 of ICTA 1988 (known as ‘Old Code’)

Full name of Scheme

Name & Address of Scheme Administrator/ Trustee

Purchase Price

Have any of the benefits accrued on or after 6 April 1997? Yes No

Postcode

£

(8)

Payment of tax free cash:

Tax free cash already taken? Yes No

If tax free cash has not been taken already please provide the following information:

Is the annuitant subject to the regime of the Finance (No.2) Act 1987? Yes No

Is the annuitant subject to the regime of the Finance Act 1989? Yes No

If either of the above two questions has been answered ‘Yes’ please give the following:

Number of years and completed months pensionable service years months

Final Pensionable Remuneration Amount

Amount of tax free cash required? Maximum Amount

Maximum Benefits Test

Inland Revenue maximum pension available from this and any associated

employment i.e. before allowance for tax free cash/dependant’s annuity Amount

Maximum tax free cash available Amount

Amount of pension used for tax free cash/dependant’s annuity already Amount

Section E - Open Market Option from a Free Standing

Additional Voluntary Contribution Scheme

Full name of Scheme

Name & Address of Scheme Administrator

Purchase Price

(9)

Section F - Open Market Option from a Buy-out policy

Name & Address of Provider

Purchase Price

Have any of the benefits accrued on or after 6 April 1997? Yes No

Payment of tax free cash:

Is the annuitant subject to the regime of the Finance (No.2) Act 1987? Yes No

Is the annuitant subject to the regime of the Finance Act 1989? Yes No

If either of the above two questions has been answered ‘Yes’ please give the following:

Number of years and completed months pensionable service years months

Final Pensionable Remuneration Amount

Amount of tax free cash required? Maximum Amount

Amount of pension used for tax free cash/dependant’s annuity already Amount

(10)

Section G - Transfer(s) into the Liverpool Victoria Personal

Pension Scheme

If you are transferring more than four schemes please give additional details on separate sheets of paper. Please sign, date and attach any sheets additional to this form as they will be part of your application for this Annuity.

Arranging the transfer:When we receive this completed form, we will write to the trustees/administrator of your scheme(s) to arrange the transfer. By signing the declaration at the end of this application you give us your authority to do so.

Tax free cash:If your transferring scheme provides tax free cash you can choose to put all or some of it towards your Annuity purchase. If you choose to take cash, and the amount shown below is more than you are entitled to, we will write to you and tell you the maximum allowed.

Number of arrangements being transferred (if more than four)

Scheme 1

Full name of Scheme

Policy/Membership No.

Name and Address of insurer/scheme provider

Postcode

Please give the transfer value from this scheme (including any tax

free cash). If you do not know the exact figure please estimate: Amount

Scheme 2

Full name of Scheme

Postcode

free cash). If you do not know the exact figure please estimate: Amount £

(11)

Scheme 3

Full name of Scheme

Postcode

free cash). If you do not know the exact figure please estimate: Amount

Scheme 4

Full name of Scheme

Postcode

free cash). If you do not know the exact figure please estimate: Amount £

(12)

Scheme Administrators/Trustees/Insurers Statement

-Open Market Options

a. I/we confirm that the information given in this application by me/us is to the best of my/our knowledge and belief true and complete, and I/we will advise you promptly in writing of any change which affects this information.

b. I/we agree that Liverpool Victoria set up a With Profits Pension Annuity on the basis of the information contained in this application.

c. I/We understand that the annuity cannot start until this application has been accepted by you and all the purchase monies have been paid in full.

Signed for and on behalf of the administrator/trustee/insurer* (* please delete as appropriate)

Signed Date

Name and position of signatory

Section I - Documents we need with this application

We cannot start your Annuity until we have received all relevant items from the list below. Please tick to show the items enclosed with this application:

Additional pension scheme details

Separate sheets showing relevant details are only required if you are transferring money from more than four different pension schemes. Please remember to sign and date each additional sheet supplied

Annuitant’s Birth Certificate

If your name now is different from your birth certificate we will need one or more of the following, depending on why your name has changed:

Marriage Certificate Decree(s) absolute Deed poll(s)

P45 for the current tax year

This is not essential, but if you have one, please forward parts 2 and 3

If a dependant’s annuity has been chosen:

Dependant’s Birth Certificate

If the dependant’s name now is different from the name on the birth certificate we will also need one or more of the following, depending on why the name has changed:

Marriage Certificate Decree(s) absolute Deed poll(s)

IFA/WPPA/App/01867 0102

The With Profits Pension Annuity is issued by Liverpool Victoria Friendly Society Limited. Regulated by the FSA. Member of the ABI. Registered Office: County Gates, Bournemouth BH1 2NF.

Client Administration Centre: Liverpool Victoria Friendly Society Limited, PO Box 67, The Ziggurat, 25 Grosvenor Road, St Albans, Herts, AL1 3YL.

Telephone 0845 60 23 690.