Fillable ADDITIONAL PAYMENT FORM FOR INDIVIDUAL PLAN OWNERS PIMS (RL360)

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ADDITIONAL PAYMENT FORM FOR INDIVIDUAL PLAN OWNERS PIMS (RL360)

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1
Please complete this form in BLOCK CAPITALS throughout.
This form is for plan owners who wish to make an additional payment into their PIMS plan.
Corporate and Trustee plan owners must complete Additional Payment Form – ref. PM03.
Company and Individual Trustee plan owners must complete Additional Payment Form – ref. PM04.
You can download these forms from our website www.rl360.com.
Once you have completed and signed the form, you should send it along with all requested additional information to:
newbusiness@rl360.com or alternatively post it to: New Business Team, RL360, International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, British Isles.
01 PLAN DETAILS
Plan reference
Plan owner 1 Plan owner 2
Name
Country of residence
for tax purposes
Tax Identification
Number (TIN)
If unavailable, provide a functional equivalent (eg National Insurance Number, Social Security Number, resident registration number)
Are you a Specified US Person?
Yes
No
Yes
No
Specified US Person means a US citizen or tax resident individual who has a US residential/correspondence address or who
either holds a US Passport, a US Green Card or who was born in the US and has not yet renounced their US citizenship. More
information on US FATCA can be found at: www.irs.gov/Businesses/Corporations/Foreign-Account-Tax-Compliance-Act-FATCA
If you choose Yes to being a Specified US Person, you will need to provide us with your US Taxpayer Identification Number (TIN)
or US Social Security Number (SSN).
If you choose No but you have a US residential/correspondence address, hold a US Passport, a US Green Card or you were born
in the US, you will need to provide us with documentary evidence that you are in the process of or have renounced your US
Citizenship. RL360 can accept a certified copy of your DS-4083 form (also known as CLN – Certificate of Loss of Nationality)
and/or a certified copy of your passport for the country in which you have obtained new citizenship.
Do you want to update your contact/address details as part of this application?
Yes
No
If yes then please provide new details in Section 05 - Additional Information.
Online services
If you haven’t yet registered for online access to your plan but would like to, download our
agreement and registration forms from our website - www.rl360.com.
PIMS
ADDITIONAL
PAYMENT FORM
FOR INDIVIDUAL
PLAN OWNERS
2
02 PAYMENT DETAILS
Please confirm the amount of your additional payment below:
Additional payment (Currency and cash amount)
+
Additional payment (if in a (Currency and cash amount)
dierent currency to the above)
+
Asset exchange value (if any) (Cash amount)
+
Asset transfer value (if any) (Existing assets to be added directly into your plan)
=
Total payment
Please confirm the details of the bank that you will be making payment from.
If you want to use a Currency Exchange House to transfer your payment to us, please ensure that it has been approved by
RL360 first. Please also provide your bank account details below from where the payment originates, along with a full audit trail
to evidence the transfer to us.
Bank name
Bank address and
postcode
Account holder’s name
Branch SWIFT code
OR Bank sort code
- -
(for all non–GBP and international payments) (for UK GBP payments only)
SWIFT code must be either 8 or 11 digits
IBAN/account number
OR
Account number
(all non–GBP accounts) (GBP UK Bank only)
Account held for
years
months
Who will fund the
The plan owner(s)
Employer
Spouse
additional payment?
Parent
Other
3
03 ASSET REQUIREMENTS
Please choose from the following options below:
Option 1 - Quick selection
Please choose only one of the following options.
Please send all of my additional payment to my chosen discretionary manager (if applicable)
Please allocate all of my additional payment to my PIMS cash account(s) (I will supply a Dealing Instruction Form at a
later date)
OR
Option 2 - Your PIMS assets
Please tell us the percentages of your additional payment that you want to be applied to each asset.
PIMS cash account
1
Percentage
You must maintain at least 2% of your plan value in the PIMS cash account %
Bank or building society name Cash deposit name Percentage
%
ISIN or Sedol code
Asset manager
2
Asset name (including currency) Percentage
%
%
%
%
%
%
%
%
%
%
%
%
Total 100%
1
Assuming your plan cash account already has a positive balance, there is no need to enter a percentage.
2
Please be aware that Asset managers may impose minimum amounts that they will allow to be sold or purchased and you must
adhere to these. Any income from distributing assets will automatically be credited to your PIMS cash account.
4
04 SOURCE OF WEALTH
The Insurance (Anti-Money Laundering) Regulations 2008 requires all Isle of Man life companies to make enquiries as to how an
applicant has acquired the monies to be used as payment for their plan. This reflects the Isle of Man’s commitment to maintain
the highest possible standards of business practice and to counter money laundering and the financing of terrorism.
RL360 has adopted a risk-based approach to meet these regulations, categorising all countries that we will accept business from
into 1 of 3 tiers. Each tier has dierent source of wealth requirements. We have categorised countries according to their level of
compliance with international regulatory standards.
Full details on the source of wealth procedures can be obtained from your financial adviser or can be downloaded from
www.rl360.com/sourceofwealth.pdf.
You must complete the following questions in full, in all cases, and for both plan owners as applicable.
Plan owner 1 Plan owner 2
Annual salary plus bonuses
Income this year
(include currency)
Income last year
(include currency)
Occupation
Employer’s company
name
Nature of business
Other unearned income
Amount received
(include currency)
Received from
Date received (dd/mm/yyyy)
If you are retired please tell us your previous occupation, salary, employer and date of retirement.
Previous occupation
Salary
(include currency)
Employer’s company
name
Date retired (dd/mm/yyyy)
Where your source of wealth for this application is from any of the following, please provide details.
Savings
Amount received
(include currency)
Bank where savings
were held
How were savings
accumulated?
5
04 SOURCE OF WEALTH DETAILS CONTINUED
Plan owner 1 Plan owner 2
Pension transfer
Amount received
(include currency)
Received from
Date received (dd/mm/yyyy)
Property or asset sale
Amount received
(include currency)
Address of property
sold or asset type
How long held
Date of sale (dd/mm/yyyy)
Company profits
Profits this year
(include currency)
Profits last year
(include currency)
Industry
Company sale
Amount received
(include currency)
Company name
Company industry
Date received (dd/mm/yyyy)
Other (such as a lottery or betting win, gift or inheritance. For inheritance please state from who.)
Amount received
(include currency)
Source
Date received (dd/mm/yyyy)
RL360 reserves the right to request further documentary evidence of source of wealth should it be considered necessary.
6
05 ADDITIONAL INFORMATION
If you have no additional notes, please continue to Section 06 - Declaration.
7
06 DECLARATION
My application
I understand that my additional payment will be treated in line with the terms and conditions of my plan.
Key Information Document (KID)
I confirm that I have included a KID with this Additional Payment Form.
I understand that the KID sets out the details of my additional payment and the charges that will be deducted.
Illustration
I confirm that I have included an Illustration with this Additional Payment Form.
I understand that my Illustration is not guaranteed by RL360 or my adviser, and only oers an indication of what I might get
back under a limited number of scenarios.
Availability
I confirm that to the best of my knowledge and belief, I am not subject to any legislation that would make my additional
payment unlawful.
Investment
I understand that RL360 is not responsible for the choice of assets within my plan.
I agree to RL360 acting on dealing instructions received from me or my appointed adviser, and I will read all of the
documentation issued by the manager for each asset.
Privacy policy
Our full privacy policy can be viewed at www.rl360.com/privacy or can be obtained by requesting a copy from our Data
Protection Ocer.
Legal
I agree to my plan being governed by Isle of Man law and to the Isle of Man Courts having the right to decide any case that may
be brought in relation to it.
Cancellation
I am aware that I have the right to cancel my additional payment as detailed in the Key Information Document. I understand that
the amount I get back may be less than what I paid where my selected assets have fallen in value. I am aware that to cancel my
additional payment I will need to complete the Cancellation Notice and return it to RL360.
I accept that RL360 can bring my plan to an end if I have failed to disclose any facts that may influence the decision to accept
this additional payment application.
I confirm that this additional payment form was signed in (give country)
Plan owner 1 Plan owner 2
Signed
Date (dd/mm/yyyy)
8
07 ADVISER DETAILS
This section is to be completed by your financial adviser.
The RL360 adviser number can be obtained from your regional oce.
Company name
Adviser number
Name of regulatory or
authorising body
Regulatory number
(if applicable)
Financial adviser’s stamp
(if this does not state an
address, please complete
company address details too)
Full name
Online services username
(if registered)
Work telephone number
Mobile telephone number
Email address
I confirm that I have seen documentary proof of identity for the plan owner(s), and certification of their residential address, and
have, where applicable, attached suitably certified copies of both.
Signed
Date (dd/mm/yyyy)
PM02c 12/20
RL360 Insurance Company Limited. Registered Oce: International House, Cooil Road, Douglas,
Isle of Man, IM2 2SP, British Isles. Registered in the Isle of Man number 053002C. RL360
Insurance Company Limited is authorised by the Isle of Man Financial Services Authority.
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ADDITIONAL PAYMENT FORM FOR INDIVIDUAL PLAN OWNERS PIMS (RL360)

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Completed 21 June 2021

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