Fillable FORM ADDITIONAL CONTRIBUTION (RL360)

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FORM ADDITIONAL CONTRIBUTION (RL360)

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1
Please complete this form in BLOCK CAPITALS throughout.
SECTION 1 POLICY DETAILS
Policy number
Are you notifying us of any changes to your personal/company/trustee details as part of this application?
Yes
No
If yes, please provide details in Section 6 – Your additional notes.
Policyholder 1 Policyholder 2 (if applicable)
Name
Country of residence for
tax purposes
Tax Reference Number
(ie TIN/NI)
Are you a Specified US Person?
Yes
No
Yes
No
Country and
place of birth
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.
If the policyholder is a trust, company or corporate trustee, please complete Section 3 and 4.
ADDITIONAL CONTRIBUTION
FORM
PARAGON
2
SECTION 2 CONTRIBUTION DETAILS
Do you want to increase your regular premiums or top-up with a single premium injection?
Regular premium increase
Single premium injection
Regular premium details
The premium currency, method of payment and payment frequency for increased regular premiums will be the same as your
current premiums.
Current regular premium
Additional regular premium*
Total regular premium
* For details on the minimum additional premiums applicable to your policy, please refer to the relevant policy literature.
Unless otherwise instructed, additional regular premiums will be invested as per your current instructions.
Single premium injection
Additional single premium injection
(currency and amount)
Payment details
Cheque
Telegraphic transfer
Payments by cheque or telegraphic transfer
Please confirm the details of the bank that you will be making payment from.
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
Is the money being invested your own? Yes No
If no, please provide full details in Section 6 – Your additional notes (we may ask for further documentary evidence).
3
SECTION 2 CONTRIBUTION DETAILS CONTINUED
Fund selection for the single premium injection only
ISIN Fund name Currency
Percentage
of premium
%
%
%
%
%
%
%
%
%
%
Total 100%
Please note that the maximum number of funds allowed is 10 (including existing funds).
SECTION 3 SUPPLEMENTARY SECTION FOR CORPORATE TRUSTEES
Corporate trustee name
Global Intermediary Identification
Number (FATCA GIIN)
4
SECTION 4 SUPPLEMENTARY SECTION FOR TRUSTS, COMPANIES AND CORPORATE TRUSTEES
Trusts
Trust name
Settlor 1 Settlor 2 (if applicable)
Name
Country of residence for
tax purposes
Tax Reference Number
(ie TIN/NI)
Country and
place of birth
Trustee 1 Trustee 2
Name
Date of birth (dd/mm/yyyy)
Country of residence for
tax purposes
Tax Reference Number
(ie TIN/NI)
Are you a Specified US Person?
Yes
No
Yes
No
Country and
place of birth
Trustee 3 Trustee 4
Name
Date of birth (dd/mm/yyyy)
Country of residence for
tax purposes
Tax Reference Number
(ie TIN/NI)
Are you a Specified US Person?
Yes
No
Yes
No
Country and
place of birth
Companies
Company name
Executive Director/Partner 1 Director/Partner 2
Name
Date of birth (dd/mm/yyyy)
Country of residence for
tax purposes
Tax Reference Number
(ie TIN/NI)
Are you a Specified US Person?
Yes
No
Yes
No
Country and
place of birth
5
SECTION 4 SUPPLEMENTARY SECTION FOR TRUSTS AND COMPANIES CONTINUED
Shareholders and beneficial interest
Please complete this section for persons who have a shareholding or beneficial interest of 25% or more.
Shareholder 1 Shareholder 2 (if applicable)
First name(s)
Last name
Date of birth (dd/mm/yyyy)
Country and
place of birth
Position held
Shareholding (%)
Country of residence for
tax purposes
Tax Reference Number
(ie TIN/NI)
Are you a Specified US Person?
Yes
No
Yes
No
Shareholder 3 (if applicable) Shareholder 4 (if applicable)
First name(s)
Last name
Date of birth (dd/mm/yyyy)
Country and
place of birth
Position held
Shareholding (%)
Country of residence for
tax purposes
Tax Reference Number
(ie TIN/NI)
Are you a Specified US Person?
Yes
No
Yes
No
6
SECTION 5 YOUR 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 premium for, or contribution to, a policy.” 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 annual salary question in full, in all cases and for both applicants as applicable. You must also
complete all other relevant questions within this section. Please use Section 6 if you require more space for details.
First policyholder Second policyholder (if applicable)
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)
Savings
Amount received
(include currency)
Bank where savings
were held
How were savings
accumulated?
7
SECTION 5 YOUR SOURCE OF WEALTH CONTINUED
First policyholder Second policyholder (if applicable)
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)
Maturing investments or policy claim
Amount received
(include currency)
From which
company
Date received (dd/mm/yyyy)
Amount received
(include currency)
From which
company
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.
8
SECTION 6 YOUR ADDITIONAL NOTES
If you have no additional notes, please continue to Section 7 – Your declaration.
SECTION 7 YOUR DECLARATION
My application
I understand that my additional premium will be treated in line with the terms and conditions of my policy.
Availability
I confirm that to the best of my knowledge and belief, I am not subject to any legislation that would make my investment into
Quantum unlawful.
Investment
I understand that RL360 is not responsible for the choice of investments within my Quantum policy.
I agree to RL360 acting on investment instructions received from me or my appointed adviser, despite the fact I may not have read
all of the documentation issued by the investment manager for each fund.
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 the policy 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 the policy.
I accept that RL360 can bring the contract to an end if I have failed to detail any facts that may influence the decision to accept
this application.
I confirm that this application was signed in (give country)
Policyholder/Trustee/Authorised Signatory 1 Policyholder/Trustee/Authorised Signatory 2
Full name
Signed
Date (dd/mm/yyyy)
Policyholder/Trustee/Authorised Signatory 3 Policyholder/Trustee/Authorised Signatory 4
Full name
Signed
Date (dd/mm/yyyy)
9
SECTION 8 YOUR ADVISER’S DECLARATION
This section is to be completed by your financial adviser.
The RL360 adviser number can be obtained from your regional oce.
Company name
RL360 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 the applicant(s) identity, and certification of their residential address, and have,
where applicable, attached suitably certified copies of both as set out in the completion notes, along with this application.
Signed
Date (dd/mm/yyyy)
PAR034f 04/21
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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FORM ADDITIONAL CONTRIBUTION (RL360)

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Completed 21 June 2021

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