Fillable FORM FOR COMPANY: ADDITIONAL PAYMENT AND INDIVIDUAL TRUSTEE (RL360 Adviser)

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FORM FOR COMPANY: ADDITIONAL PAYMENT AND INDIVIDUAL TRUSTEE (RL360 Adviser)

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1
Please complete this form in BLOCK CAPITALS throughout.
Individual plan owners must complete Additional Payment form - ref. RS02.
Corporate Trustee plan owners must complete Additional Payment form - ref. RS03.
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:
Email: newbusiness@rl360.com
or alternatively post it to:
New Business Team
RL360
International House
Cooil Road
Douglas
Isle of Man
IM2 2SP
British Isles
Specified US Person
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 in which you are obtaining new citizenship.
Automatic Exchange of Information - Entity Self Certification
Automatic Exchange of Information (AEOI) is the United States Foreign Account Tax Compliance Act (FATCA) and the
Organisation of Economic Cooperation and Development (OECD) Common Reporting Standards (CRS). Under these tax
regulations and intergovernmental agreements entered into by the Isle of Man, we are required to collect information which may
be exchanged by the Isle of Man Government with other jurisdictions. In order for us to comply with these requirements, you will
need to complete the appropriate AEOI Self-Certification Forms in addition to this application form.
Details of who is considered to be a controlling person under AEOI can be found in our AEOI Definitions document which can be
found here https://www.rl360.com/generic/downloads/tech032.pdf
The AEOI Entity and Individual Self-Certification Forms can be found here: www.rl360.com/row/downloads/forms.htm
ADDITIONAL PAYMENT
FORM FOR COMPANY
AND INDIVIDUAL
TRUSTEE OWNERS
REGULAR SAVINGS PLAN
2
01 COMPANY DETAILS
You are required to complete an Automatic Exchange of Information - Entity Self Certification form - ref. tech031 as part of
this application. You can download a copy from www.rl360.com.
Plan reference
Company name
Executive Director/Partner 1 Director/Partner 2
First name(s)
Last name(s)
Country of incorporation incorporation/organisation
Date of birth (dd/mm/yyyy)
Country of birth
Country or 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
Shareholders and beneficial interest
Please complete this section for persons who have a shareholding or beneficial interest of 25% or more.
Please see page 1 for a definition of Specified US Person and for the information a Specified US Person must provide.
Shareholder 1 Shareholder 2 (if applicable)
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Country of birth
Position held
Shareholding (%)
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
Shareholder 3 (if applicable) Shareholder 4 (if applicable)
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Country of birth
Position held
Shareholding (%)
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
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.
3
02 INDIVIDUAL TRUSTEE DETAILS
Automatic Exchange of Information - Entity Self Certification
You are required to complete an Automatic Exchange of Information - Entity Self Certification form - ref. tech031 as part of
this application. You can download a copy from www.rl360.com.
Where the trust is a bare/absolute trust, you will also need to provide the following information in respect of the beneficiaries:
name, date of birth, residential address, country/countries of residence for tax purposes, Tax Identification Number (TIN) or
functional equivalent.
Plan reference
Settlor 1 Settlor 2
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Country of birth
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
Trustee 1 Trustee 2
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Country of birth
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
Trustee 3 Trustee 4
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Country of birth
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
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, please download our agreement and registration forms
from our website – www.rl360.com
4
03 PAYMENT DETAILS
You can use this form to increase regular payments and/or add a lump sum payment to your plan. Use the tick boxes to indicate
which options you require.
Regular payment increase
Current payment
Payment increase
Total payment
Establishment period (months)
Your plan currency, frequency and method of payment will remain unchanged.
Fund selection
Your payment increase will be invested in-line with your current fund selection.
If you wish to amend your current fund selection you will be required to complete a fund switch request form.
Additional lump sum
Lump sum
Payment options
Cheque
Telegraphic transfer
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
Fund selection (required)
We will invest your lump sum as per the fund selection provided in the table below:
ISIN Fund name Currency Percentage
of payment
%
%
%
%
%
%
%
%
%
%
100%
5
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.
Trustee applicants must complete the following questions below in all cases and for both Settlors as applicable.
Applicant/Settlor 1 Settlor 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?
6
04 SOURCE OF WEALTH DETAILS CONTINUED
Applicant/Settlor 1 Settlor 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.
7
05 ADDITIONAL INFORMATION
If you have no additional notes, please continue to Section 06 - Declaration.
8
06 DECLARATION
My application
I am aware that my payment increase and/or lump sum will be treated in line with the terms and conditions of my plan.
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.
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.
Availability
I confirm that to the best of my knowledge and belief, I am not subject to any legislation that would make my payment increase/
lump sum unlawful.
Investment
I am aware that RL360 is not responsible for the choice of funds within my plan.
I agree to RL360 acting on investment instructions received from me or my appointed adviser, and I will 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 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 funds 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)
Authorised signatory/Trustee 1 Authorised signatory/Trustee 2
Full name
Signed
Date (dd/mm/yyyy)
Authorised signatory/Trustee 3 Authorised signatory/Trustee 4
Full name
Signed
Date (dd/mm/yyyy)
9
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
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 plan owner’s identity, and certification of their residential address, and have,
where applicable, attached suitably certified copies of both.
Signed
Date (dd/mm/yyyy)
RS04d 12/19
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 FOR COMPANY: ADDITIONAL PAYMENT AND INDIVIDUAL TRUSTEE (RL360 Adviser)

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Completed 27 March 2021

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