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

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

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1
Please complete this form in BLOCK CAPITALS throughout.
Individual plan owners must complete Additional Payment form - ref. OR01.
Corporate Trustee plan owners must complete Additional Payment form - ref. OR02.
You can download these forms from our website www.rl360.com.
01 COMPANY DETAILS
Plan reference
Company name
Executive Director/Partner 1 Director/Partner 2
First name(s)
Last name(s)
Country of
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)
Is the Entity a US
Yes
No
Yes
No
Specified Person?
US Specified Person means a US citizen or tax resident individual, who either holds a US Passport, a US Green
Card, has a US residential/correspondence address 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.
ADDITIONAL PAYMENT
FORM FOR COMPANY
AND INDIVIDUAL
TRUSTEE OWNERS
ORACLE
2
01 COMPANY DETAILS 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(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 US Specified 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 US Specified 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 06 - Additional Information.
AUTOMATIC EXCHANGE OF INFORMATION – ENTITY SELF-CERTIFICATION
Instructions for completion
Under Tax Regulations and intergovernmental agreements entered into by the Isle of Man in relation to the automatic exchange of
information for tax matters (collectively “AEOI”), RL360 is required to collect information about each applicant’s tax status.
This section is for applicants who are classified as an Entity under the Tax Regulations. For a definition of AEOI Entity Types,
download our AEOI Definitions at: http://www.rl360.com/row/downloads/forms.htm
Please note that in certain circumstances the information you provide may be disclosed to the Isle of Man Income Tax Division who in
turn may exchange this information with tax authorities in other jurisdictions.
If any of the information that you provide changes in the future, you must advise us of these changes by completing a new Entity
Self-Certification form and/or an Individual Self Certification as appropriate.
Please note that your Common Reporting Standards (CRS) classification does not necessarily coincide with your classification
for US FATCA purposes.
3
01 COMPANY DETAILS CONTINUED
PART A – Passive Non-Financial Entity (NFE) and Passive Non-Financial Foreign Entity (NFFE)
If the entity is a NFE or NFFE please tick here and complete Parts A (i) and Part C
If the entity is not an NFE or NFFE, please complete Part B and Part C.
If the entity is a Specified US Person, please complete our AEOI Entity Self-Certification Form which you can download from
http://www.rl360.com/row/downloads/forms.htm
PART A (i) - Entity Declaration of Tax Residency
Country/countries of tax residency Taxpayer Identification Number
(TIN) or functional equivalent
Reference number type (TIN, Business
Registration Number, other (please
specify)).
PART B – Please complete if you are NOT an NFE or NFFE
Please provide your Common Reporting Standards (CRS) classification by ticking the appropriate box(es).
If the entity is a Financial Institution, please specify the type of Financial Institution below:
Reporting Financial Institution under CRS.
OR
Non-Reporting Financial Institution under CRS. Specify the type of Non-Reporting Financial Institution below:
Governmental Entity
International Organisation
Central Bank
Broad Participation Retirement Fund
Narrow Participation Retirement Fund
Pension Fund of a Governmental Entity, International Organisation, or Central Bank
Exempt Collective Investment Vehicle
Trust whose trustee reports all required information with respect to all CRS Reportable Accounts
Qualified Credit Card Issuer
Other Entity defined under the domestic law as low risk of being used to evade tax.
Specify the type provided in the domestic law:
If the Financial Institution is resident in a Non-Participating Jurisdiction under CRS, please specify the type of Financial
Institution resident in a Non-Participating Jurisdiction below:
a)
Investment Entity and managed by another Financial Institution.
If you have ticked this box, your Controlling Persons will each need to complete an RL360 AEOI Individual
Self-Certification Form.
b) Other Financial Institution, including a Depositary Financial Institution, Custodial Institution, or Specified Insurance Company.
c) Other Investment Entity
If the entity is an Active Non-Financial Entity (“NFE”) please specify the type of NFE below:
a)
Corp
oration that is regularly traded or a related entity of a regularly traded corporation.
Provide the name of the stock exchange where traded:
b) If you are a related entity of a regularly traded corporation, provide the name of the regularly traded corporation:
4
01 COMPANY DETAILS CONTINUED
c) Governmental Entity, International Organisation, a Central Bank, or an Entity wholly owned by one or more of the foregoing
d) Other
Active Non-Financial Foreign Entity
PART C – US FATCA Classification for all non-US Entities
If you are a US Entity, please complete our AEOI Entity Self-Certification Form which you can download from
http://www.rl360.com/row/downloads/forms.htm
Please complete this section if the entity is not a US Tax Resident
If the entity is a Registered Financial Institution, please tick one of the below categories, and provide the entity’s GIIN.
a)
IGA Partner Jurisdiction Financial Institution
b) Registered Deemed Compliant Foreign Financial Institution
c) Pa
rticipating Foreign Financial Institution
Global Intermediary Identification number (GIIN):
If the entity is a Financial Institution but unable to provide a GIIN, please tick one of the below reasons:
a)
The Entity is a Sponsored Financial Institution and has not yet obtained a GIIN but is sponsored by another entity that has
registered as a Sponsoring Entity. Please provide the Sponsoring Entity’s name and GIIN.
Sponsoring Entity’s Name:
Sponsoring Entity’s GIIN:
b)
The Entity is a Trustee Documented Trust. Please provide your Trustee’s name and GIIN.
Trustee’s Name:
Trustee’s GIIN:
c)
The Entity is a Certified Deemed Compliant, or otherwise Non-Reporting, Foreign Financial Institution (including a Foreign
Financial Institution deemed compliant under Annex II of an IGA, except for a Trustee Documented Trust or Sponsored
Financial Institution).
Indicate exemption:
d) The Entity is a Non-Participating Foreign Financial Institution.
If the entity is not a Foreign Financial Institution, please confirm the Entity’s FATCA status below:
a)
The Entity is an Exempt Beneficial Owner Indicate status:
b)
The Entity is a
Passive Non-Financial Foreign Entity
(Passive NFFE)
If you have ticked this box, your Controlling Persons will each need to complete an RL360 AEOI Individual
Self-Certification Form.
c)
The Entity is an Active Non-Financial Foreign Entity (including an Excepted NFFE)
i. If the Entity is a Direct Reporting NFFE, please provide the Entity’s GIIN:
ii.
If the Entity is a Sponsored Direct Reporting NFFE, please provide the Sponsoring Entity’s name and GIIN.
Sponsoring Entity’s name:
Sponsoring Entity’s GIIN:
5
02 INDIVIDUAL TRUSTEE DETAILS
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 US Specified 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 US Specified 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 US Specified Person?
Yes
No
Yes
No
US Specified Person means a US citizen or tax resident individual, who either holds a US Passport, a US Green Card, has a US
residential/correspondence address 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.
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
6
03 PAYMENT DETAILS
Please confirm the amount of your additional payment below:
Additional payment (Currency and cash amount)
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 additional
The plan owner(s)
Employer
Spouse
payment?
Parent
Other
7
04 FUND REQUIREMENTS
Please list your choice of funds below. There are no limits to the number of funds you can hold in your plan subject to the
minimum investment level of GBP500 per fund. Please refer to the Product Guide for currency equivalent minimums.
Please ensure that the percentages invested total 100% of the payment.
Note: If you require more room then please use the space provided in Section 06 - Additional information.
ISIN Fund managers Fund name Percentage
%
%
%
%
%
%
%
%
%
%
%
%
Total 100%
8
05 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?
9
05 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 fund sale
Amount received
(include currency)
Address of property
sold or fund 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.
10
06 ADDITIONAL INFORMATION
If you have no additional notes, please continue to Section 07 - Declaration.
11
07 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.
Key Information Document (KID)
I confirm that I have included a signed KID with this Additional Payment Form.
I understand that the KID sets out the details of my additional payment, and by signing it I acknowledge that I am aware of the
charges that will be deducted.
I am also aware that the payment details provided in Section 03 must match my signed KID. If they are dierent, RL360 will ask
me to sign a new KID matching Section 03 before my additional payment can be added to my plan.
Illustration
I confirm that I have included a signed 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 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)
12
08 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)
OR03 a 07/ 1 9
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)

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Completed 21 June 2021

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