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LIFE ASSURANCE (RL360)

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PERSONAL
INVESTMENT
MANAGEMENT
SERVICE
APPLICATION
FORM
LIFE ASSURANCE
TABLE
OF
CONTENTS
01
PAGE 1
YOUR DETAILS
02
PAGE 2
LIVES ASSURED
03
PAGE 3
PLAN REQUIREMENTS
04
PAGE 4
ASSET REQUIREMENTS
05
PAGE 5
SOURCE OF FUNDS DETAILS
In this section, tell us how your funds
were accumulated. It is important
that you complete this section so that
we can meet Isle of Man anti-money
laundering requirements.
06
PAGE 7
REGULAR WITHDRAWALS
07
PAGE 7
ADDITIONAL INFORMATION
08
PAGE 8
DECLARATION
In this section you must agree to the
plan terms and conditions and sign
where appropriate.
09
PAGE 10
FINANCIAL ADVISER DETAILS
10
PAGE 10
APPLICATION CHECKLIST
11
PAGE 12
PAYMENT METHODS
12
PAGE 13
REQUEST TO PAY
FINANCIAL ADVISER CHARGE
(OPTIONAL)
13
PAGE 14
REQUEST TO APPOINT
INVESTMENT ADVISER AND
PAY CHARGE (OPTIONAL)
COMPLETION
Please complete this form using BLOCK CAPITALS throughout. Please tick boxes where applicable and follow the instructions
provided in each section. Please use Section 10 - Application Checklist before submitting your application, to make sure that you
provide us with everything we need to process your application.
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.
A copy of the completed application and the plan Terms and Conditions are available on request. You should be aware that your
plan could be brought to an end if you fail to tell us any facts which might influence our assessment of your application. If you have
any doubt as to whether a fact is relevant, then you should disclose it to us.
We will accept emailed or faxed scans of applications. However, we reserve the right to request original documents in some
circumstances, so these must be retained in your records. Where the policyholder is resident in Africa, we will still require
original signed instructions.
Once you have completed and signed the application, 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.
Please note that the start date of your plan may be delayed if you fail to complete this application in full or provide suitable
evidence where required.
Remember, if you need any help, our Regional Support teams are on hand to guide you by telephone or by email.
All references to RL360 within this application form mean RL360 Insurance Company Limited.
All references to PIMS within this application form mean Personal Investment Management Services.
1 PIMS APPLICATION FORM - LIFE ASSURANCE
01 YOUR DETAI L S
You should provide us with verification of your identity and current residential address (see page 10 for details).
Applicant 1 Applicant 2
Sex (please tick)
Male
Female
Male
Female
Title (please tick)
Mr
Mrs
Miss
Mr
Mrs
Miss
Other (in full) Other (in full)
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Country of birth
Nationality
Country of residence
for
tax purposes
Tax Identification Number (TIN)
If unavailable, provide a functional equivalent (e.g National Insurance number, Social Security number, Resident Registration number).
Are you a Specified US Person?
Yes
No
Yes
No
Current residential
address and
postcode (in full)
Country
Home telephone number
Mobile telephone number
Relationship to Applicant 1
Online services
If you wish to access details of your plan online, you must supply us with the following information.
Email address
Password (you will
only use this once)
Password hint
Correspondence details
Please note that any correspondence we are required to send to you will be sent to the address you provide here. If no
correspondence address is supplied we will use the current residential address of the first applicant.
Address and
postcode for
correspondence
Is this address for
You
Your financial adviser
A friend
A family member
PIMS APPLICATION FORM - LIFE ASSURANCE 2
02 LIVES ASSURED
There may be up to 6 lives assured added to the plan. At least 1 life assured must be younger than 75 when the plan starts. If either
applicant is a life assured, tick the appropriate box below and proceed to Section 03 - Plan Requirements.
Applicant 1 is a life assured
Applicant 2 is a life assured
Life assured 1 Life assured 2
Sex (please tick)
Male
Female
Male
Female
Title (please tick)
Mr
Mrs
Miss
Mr
Mrs
Miss
Other (in full) Other (in full)
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Nationality
Current residential
address and
postcode (in full)
Country
Life assured 3 Life assured 4
Sex (please tick)
Male
Female
Male
Female
Title (please tick)
Mr
Mrs
Miss
Mr
Mrs
Miss
Other (in full) Other (in full)
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Nationality
Current residential
address and
postcode (in full)
Country
Life assured 5 Life assured 6
Sex (please tick)
Male
Female
Male
Female
Title (please tick)
Mr
Mrs
Miss
Mr
Mrs
Miss
Other (in full) Other (in full)
First name(s)
Last name(s)
Date of birth (dd/mm/yyyy)
Nationality
Current residential
address and
postcode (in full)
Country
3 PIMS APPLICATION FORM - LIFE ASSURANCE
03 PLAN REQUIREMENTS
Who will fund the plan ?
The applicant(s)
Employer
Spouse
Parent
Other
If the payer is anyone other than the applicant(s), please refer to Section 10 - Application Checklist, Third party payments for
further details.
IMPORTANT: The following information MUST match the details shown on your Key Information Document.
Plan currency
Please tick only one:
GBP
USD
EUR CHF
AUD
HKD
JPY
Payment
Please remember the minimum payment is GBP50,000 or currency equivalent. Please refer to the Product Guide for currency
equivalent minimums. Where you are transferring assets please provide an estimated value.
Your initial payment will be applied to your plan in the currency(ies) paid to us.
Amount (Currency and cash amount)
+
Asset transfer value (if any) (Existing assets to be added directly into your plan)
=
Total payment
Segments
Please state your required number of segments. The minimum number of segments is 1 and the maximum is 100. If you leave this
blank we will issue your plan with 100 segments.
Number of
segments
IMPORTANT:
some banking institutions may deduct charges for processing international payments. Please check with your
bank if any charges will apply prior to transferring your payment to us. If they do, please make sure that the amount your bank
transfers is enough, so that the remaining amount received is at least equal to the amount due.
Payments by telegraphic transfer or cheque
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
PIMS APPLICATION FORM - LIFE ASSURANCE 4
04 ASSET REQUIREMENTS
If you wish to use an investment adviser you should complete our Request to appoint Investment Adviser form, returning it along
with your application. If you need additional space to complete this section, please use Section 07 – Additional Information.
The payment and any asset transfer value will be used to calculate the amount linked to each of your chosen assets. Asset
transfers will be added into the plan directly.
Quick selection
Please allocate my payment to the PIMS cash account (we will supply a Dealing Instruction at a later date).
Your PIMS assets
Please tell us the percentages of the payment that you want to be applied to each asset.
PIMS cash account (mandatory
1
)
Percentage
You must place at least 2% of your total payment into the PIMS cash account %
Bank or building society name Cash deposit name Percentage
%
ISIN or Sedol code
Asset manager Asset name (including currency) Percentage
%
%
%
%
%
%
%
%
%
%
%
%
Total 100%
1
Please be aware that asset managers may impose minimum amounts that they will allow to be sold or purchased. Any income
from distributing assets will automatically be credited to your PIMS cash account.
5 PIMS APPLICATION FORM - LIFE ASSURANCE
05 SOURCE OF FUNDS DETAILS
The Isle of Man Financial Services Authority 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 our products and countries that we will
accept business from into Standard or Higher risk. We have categorised countries according to their level of compliance with
international regulatory standards.
Full details on the source of funds procedures can be obtained from your financial adviser or can be downloaded from
www.rl360.com/sourceounds.pdf.
You must complete the following details below in all cases and for both applicants as applicable.
Applicant 1 Applicant 2
Annual salary plus bonuses
Income this year
(include currency)
Income last year
(include currency)
Occupation
Employer’s company
name
Nature of business
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)
Other unearned income
Amount received
(include currency)
Received from
Date received (dd/mm/yyyy)
Where your source of funds for this application is from any of the following, please provide details.
Savings
Amount received
(include currency)
Bank where savings
were held
How and for how
long were the
savings
accumulated?
PIMS APPLICATION FORM - LIFE ASSURANCE 6
05 SOURCE OF FUNDS DETAILS CONTINUED
Applicant 1 Applicant 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 maturing investment, lottery or betting win, gift or inheritance. (For inheritance please state from who, for
maturing investments please confirm how long held).
Amount received
(include currency)
Source
Date received (dd/mm/yyyy)
RL360 reserves the right to request further documentary evidence of source of funds should it be considered necessary.
7 PIMS APPLICATION FORM - LIFE ASSURANCE
06 REGULAR WITHDRAWALS
If you do not wish to set up regular withdrawals on the plan at this stage, please continue to
Section 07
- Additional Information.
Please remember that the minimum regular withdrawal is GBP250 or currency equivalent. Regular withdrawals will be paid in the
plan currency unless you tell us otherwise in
Section 07
- Additional Information
.
How do you want to take the
As fixed amount Tell us the amount
withdrawals? (choose only one)
OR
As a percentage Tell us the percentage of the total initial payment
%
Withdrawal frequency Monthly
Quarterly
Half-yearly
Yearly
Termly
Date of first withdrawal
(dd/mm/yyyy)
Payment method
BACS
TT
BACS payments require up to three days to clear and can only be used for GBP payments to a UK
bank account. A GBP20 (or currency equivalent) charge applies to payments made by TT.
If you would like withdrawals to be paid back to the same bank account as detailed in Section 03 - Plan Requirements, please tick
below. Otherwise please specify the bank account to be used to receive withdrawals. Payments can only be made to bank accounts
in your name, as the applicant.
Please use the bank account details in Section 03 – Plan Requirements.
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
07 ADDITIONAL INFORMATION
If you have no additional notes, please continue to Section 08 - Declaration.
Please use a separate page if you require more space.
PIMS APPLICATION FORM - LIFE ASSURANCE 8
08 DECLARATION
Plan literature
I confirm that I have read a copy of the plan literature including the Product Guide, Key Information Document and Terms
and Conditions.
My application
I confirm that all of the information provided in this application, along with any supporting forms, questionnaires, statements,
reports or other information is true and complete.
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
this plan unlawful.
Financial adviser
I have appointed
(company name)
to act as my financial adviser.
I agree to RL360 disclosing all information relating to my plan to my appointed financial adviser. I will let RL360 know in writing
if I decide to change my appointed financial adviser.
Illustration
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. I accept that RL360 is not responsible for monitoring whether my plan's performance
matches the assumptions made in my Illustration.
Key Information Document (KID)
I confirm that I have included a signed KID with this application. I understand that the KID sets out the details of my plan, and
by signing it I acknowledge that I am aware of the charges that will be deducted. I am also aware that the details that I have
provided in Section 03 – Plan Requirements must match my signed KID. If they are dierent RL360 will ask me to sign a new KID
matching Section 03 – Plan Requirements before it can allow my plan to start.
Investment
I am aware that RL360 does not provide investment advice. I request that RL360 allocates the payment to the assets detailed in
Section 04 – Asset Requirements. In order for RL360 to do this, I confirm the following:
a) I agree to RL360 acting on dealing instructions received from me or the appointed investment adviser, and I will read the
documentation issued by the asset manager for each asset prior to selecting it for the plan.
b) Where the payment is allocated in full or in part to any cash deposit account(s), I am aware that I may not be covered by any
depositors compensation scheme should the deposit account provider become insolvent. I am aware that this is because
RL360 holds this account on my behalf.
I acknowledge the risks associated with linking a cash deposit account to the plan and accept that in the event of the insolvency
of my chosen deposit account provider, RL360 will have no responsibility for any loss and I could lose the full amount invested.
I am aware and acknowledge that the deposit account provider I choose to invest with may not be an institution or subsidiary
with which RL360 would normally hold balances or deposits.
c) I am aware that some assets (including cash deposits) may have terms and conditions that could:
i) restrict RL360 from realising a cash value when requested and prevent RL360 paying out benefits from the plan in a timely fashion.
ii) result in RL360 receiving the cash value from a sale in multiple instalments. If this should happen RL360 has the right not
to re-invest or pay in full, benefits from the plan until the amount has been received in full.
iii) result in RL360 receiving a payment from a sale by a means other than cash. If this should happen RL360 may require us
to cancel some or all of the plan.
iv) result in RL360 having to pay back some or all of the sale proceeds if an adjustment has to be made after the payment. If
RL360 is required to make such a repayment and the plan value is too low to cover it, or I have cancelled the plan, I agree
to compensate RL360 for any loss that it has suered as a result.
d) I accept that RL360 has the right to sell assets linked to the plan without requiring my permission. RL360 may do this if it
decides that an asset may have harmful legal or tax consequences under law.
e) I am aware that there may be fees to pay when RL360 sells one or more of the assets linked to the plan. Any fees due when
selling an asset should be detailed by the asset manager in the asset documentation.
f) I confirm that I am aware of the fees that must be paid in relation to the chosen assets. I realise that these fees are required to
cover the costs of promoting and distributing the assets, including any commission paid to my appointed adviser(s).
Applicants
a) I confirm that I have the necessary powers to take out this plan and enter into a contract with RL360.
b) I also confirm that my company has not been, and is not in the process of being, struck-o, dissolved, wound-up or terminated.
c) I agree that I will notify RL360 in writing immediately when any of the directors, list of authorised signatories or trustees change.
d) I agree that I will provide evidence of identity and current residential address when asked by RL360. I also acknowledge that
RL360 can ask for an up-to-date authorised signatory list at any time.
e) I am aware that RL360 is authorised to obtain a bank reference at any time.
9 PIMS APPLICATION FORM - LIFE ASSURANCE
08 DECLARATION CONTINUED
Data protection
This form collects your personal data. We require your personal data so we can provide you with services relating to the
performance of your plan. You may ask us to stop processing your data, however this may disrupt the services RL360 can
provide to you or may stop us being able to assist you. To find out how long we will keep your data, please refer to our privacy
policy at www.rl360.com/privacy. Any data you provide to RL360 may be shared, if allowed by law, with other companies both
inside and outside of RL360 and to persons who act on your behalf. Data and information about you can be transferred outside
of the Isle of Man and RL360 may be required to provide it to its regulator, its government or anyone else required by law.
RL360 will use your data and information to allow for the administration of your plan, prevent crime, prosecute criminals and for
market research and statistics. RL360 will, at all times, make sure that your data and information is only used in ways that are
allowed by law.
You can receive a copy of the information RL360 holds about you free of charge by writing to our Data Protection Ocer at:
RL360, International House, Cooil Road, Douglas, Isle of Man, IM2 2SP, British Isles, or by emailing dpo@rl360.com. We can reserve
the right to not send you your personal data in some circumstances - if we do we will write to you setting out the reasons why.
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.
Politically Exposed Persons
A Politically Exposed Person (PEP) is a person entrusted with prominent public functions, their immediate family members or
persons known to be close associates of such persons.
Examples of PEPs include political figures, members of the judiciary, diplomatic service ocers, managers and supervisors of
state owned enterprises and senior ranking military ocers.
Please add the names of any PEPs associated with this application in the box below.
Where this box is left blank, you are confirming that no PEPs are associated with this plan.
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
maybe brought in relation to my plan.
Cancellation
I am aware that I have the right to cancel my plan 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 plan I will need
to complete the Cancellation Notice and return it to RL360.
Final agreement
I agree to the following documents forming the basis of the contract between me and RL360:
• this Application Form
• My Key Information Document
• The Terms and Conditions
• The Plan Schedule
• Any Endorsement to the Plan Schedule.
I accept that RL360 can bring my plan 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)
Applicant 1 Applicant 2
Signed
Date (dd/mm/yyyy)
PIMS APPLICATION FORM - LIFE ASSURANCE 10
09 FINANCIAL 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 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)
10 APPLICATION CHECKLIST
This checklist will help make sure you have provided everything we need to process your application.
Verification of identify – must be provided for all applicants
Please send a suitably certified copy* of your passport or National Identity Card showing your photograph(s) – If you are unable
to provide either of these please provide a reason why and contact us to discuss other acceptable documents before sending in
your application.
Applicant 1 Applicant 2
I have provided identification (please tick to confirm)
I have provided identification (please tick to confirm)
If you are unable to provide ID please confirm why below: If you are unable to provide ID please confirm why below:
11 PIMS APPLICATION FORM - LIFE ASSURANCE
10 APPLICATION CHECKLIST CONTINUED
Verification of current residential address – must be provided for all applicants
Please send a suitably certified copy* of at least one of the following documents for each applicant. If you are unable to provide
any of the documents listed below, please provide a reason why in Section 07 – Additional Information and contact us to discuss
other acceptable documents before sending in your application.
Applicant 1
(please tick which
documents you
have sent us)
Applicant 2
(please tick which
documents you
have sent us)
Acceptable document
Latest bank account or credit card statement
Utility, rates or council tax bill (less than 3 months old). Mobile telephone bills are not
acceptable
Current driving licence
Proof of ownership or rental at current residential address
Mortgage statement
Tax assessment document
State pension, benefit book or other government produced document showing benefit
entitlement
Extract from ocial register of electors
Proof of payment for a PO Box service (which must also show the residential address)
where the PO Box shown is also the correspondence address of the applicant
Entry in local telephone directory.
Confirmation of plan details
Please make sure you have completed Section 03 – Plan Requirements and have included a signed Illustration and Key
Information Document.
I have provided my plan requirements and can confirm that they match my Key Information Document (please tick to confirm).
I have included a signed Illustration and Key Information Document (please tick to confirm).
*Suitably Certified Copy Documentation
Your financial adviser can certify your copy documents, if they hold established Terms of Business with us and, where appropriate,
have been granted Suitable Certifier status. Please consult your financial adviser to check if they can certify your documents.
If your financial adviser cannot certify your documents, we will accept certification by one of the following ‘Suitable Certifiers’:
• A Notary Public (or equivalent)
• A lawyer or advocate
• A formally appointed member of the judiciary
• An employee of RL360
• A Commissioner for Oaths
• A registrar or other civil or public servant authorised to issue or certify copy documents.
If you cannot have your documents certified by one of the above, please contact us.
The certifier must:
•
Add the statement ‘Certified as a true copy taken from the original’
•
Sign and date the copy document on all pages
•
Print their name clearly in BLOCK CAPITALS underneath their signature
•
Record the capacity or position in which they are certifying the document
•
Add their company name or ocial stamp or seal.
The documents which we receive
must
contain the original certification and stamp.
PIMS APPLICATION FORM - LIFE ASSURANCE 12
10 APPLICATION CHECKLIST CONTINUED
Third party payments
If the payer is anyone other than the applicant(s), we will require the following documentation:
Employer funding the plan for a key employee:
•
Certificate of incorporation or equivalent document showing date and place of incorporation
•
Evidence of the registered oce
•
A list of all directors and verification of identity and address of at least two directors
•
A set of the latest annual report and accounts
•
A list of all shareholders
•
Verification of the identity of all shareholders holding 25% or more of the issued share capital
Spouse/parent funding a plan for a partner/child:
•
Certified copy of the payer's ID
•
Certified copy of the payer's proof of residential address
•
Where the payer has a dierent surname to the applicant, evidence of the relationship
Other
•
Please contact RL360 to determine if the payer is acceptable and if so, what documentation will be required.
11 PAYMENT METHODS
Your payment can be paid using any of the following methods.
Telegraphic transfer
If you are paying into your plan by telegraphic transfer please instruct your bank to quote your name as a reference.
Your payment must come from the bank account you have detailed in Section 03 - Plan Requirements.
Please make your payment to RL360 Insurance Company Limited through the appropriate bank below.
Currency SWIFT code IBAN Sort code Account number Bank name Account name
AUD CITIGB2L GB45 CITI 1850 0813 1419 34 18-50-08 13141934 Citibank, London RL360
CHF CITIGB2L GB26 CITI 1850 0813 1418 88 18-50-08 13141888 Citibank, London RL360
EUR CITIGB2L GB20 CITI 1850 0813 1418 02 18-50-08 13141802 Citibank, London RL360
GBP CITIGB2L GB34 CITI 1850 0813 1420 35 18-50-08 13142035 Citibank, London RL360
HKD CITIGB2L GB10 CITI 1850 0813 1416 91 18-50-08 13141691 Citibank, London RL360
JPY CITIGB2L GB26 CITI 1850 0813 1415 00 18-50-08 13141500 Citibank, London RL360
USD CITIGB2L GB54 CITI 1850 0813 1415 78 18-50-08 13141578 Citibank, London RL360
Bank address
The bank address for all the above accounts is: Citibank, Citigroup Centre, Canada Square, Canary Wharf, London, E14 5LB, UK.
Cheque
Please send your cheque, made payable to RL360 Insurance Company Limited to RL360, International House, Cooil Road,
Douglas, Isle of Man, IM2 2SP, British Isles.
Your cheque must come from the bank account you have detailed in Section 03 – Plan Requirements.
Please note that GBP cheques can take up to five working days to clear. Other currency cheques may take considerably longer
to clear.
13 PIMS APPLICATION FORM - LIFE ASSURANCE
12 REQUEST TO PAY A FINANCIAL ADVISER CHARGE
Please complete in BLOCK capitals throughout.
Who is this form for?
This form is for applicants who wish to request the payment of a financial adviser charge from their plan. The payment will be
made to:
(adviser company and address)
RL360 adviser number:
We can only accept instructions that have been signed by all applicants.
Important notes
1. RL360 cannot be held responsible for any future tax liability that may accrue to the adviser as a result of a failure to levy tax
where it later transpires that it should have been charged. The adviser is responsible for deciding whether or not the service they
are providing is subject to any additional taxes.
2. The charge will commence from the date we receive your completed form. It will be calculated and paid each quarter from the
plan anniversary.
3 The value of any additional payments made to the original plan will be treated as part of its value when the charges are
calculated.
4. This agreement shall be subject to, and interpreted in, accordance with the laws of the Isle of Man.
5. I confirm that I will inform RL360 in writing should I wish to terminate payment of this charge. Any charge accrued to the point
where the payment is terminated will be deducted from your plan and paid to the financial adviser. No further financial adviser
charge will be taken.
6. I understand that, as a result of my request, RL360 may have to alter the Terms and Conditions of my contract to facilitate
this payment to my requested Financial Adviser. I request that all required changes are made to my Terms and Conditions and
they are eective immediately.
Applicant(s) to complete
I request the payment of a financial adviser charge from my plan. I authorise RL360 to pay the financial adviser charge to my
financial adviser in line with the following:
Financial adviser charge
%
per year, paid quarterly in arrears as percentage of my plan value (the charge should not be more than 1.5% per year).
Note: where this charge is used in conjunction with an investment adviser charge, the two charges combined cannot be more
than 2.0% per year.
Plan application dated (dd/mm/yyyy)
Applicant 1 Applicant 2
Signed
Full name
Date (dd/mm/yyyy)
PIMS APPLICATION FORM - LIFE ASSURANCE 14
13 REQUEST TO APPOINT INVESTMENT ADVISER AND PAY CHARGE
Who is this form for?
This form is for applicants who wish to request RL360 appoint an investment adviser to their plan and to pay a charge.
Investment advisers may act on a discretionary or non-discretionary basis. This is your choice and an agreement that you must
make with your investment adviser.
Completing this form
By completing this form you are requesting RL360 to appoint a company to act as an investment adviser to your plan. They will have
the power to place dealing instructions on your behalf.
We can only accept written instructions that have been signed by all owners, trustees or authorised signatories.
Please complete in BLOCK capitals throughout.
SECTION 1 INVESTMENT ADVISER APPOINTMENT
Applicant(s) to complete
I wish to request RL360 to appoint:
Investment adviser company name
to act in the capacity of an investment adviser to my plan
Application dated (dd/mm/yyyy)
I understand that my investment adviser will be able to act on my behalf, subject to the terms and conditions set out in Section 2
below, to advise on and change the assets to which the value of my plan is linked. I authorise RL360 Insurance Company Limited
(RL360) to release all relevant information relating to my plan to my investment adviser when requested.
I understand that RL360 is not responsible for any loss or liability incurred to my plan as a result of advice given, or negligence
by, my appointed investment adviser. I also understand that RL360 is not responsible for the performance of any assets linked to
my plan.
I understand that, as a result of my request, RL360 may have to alter the Terms and Conditions of my contract to facilitate this
payment to my requested Investment Adviser. I request that all required changes are made to my Terms and Conditions and
they are eective immediately.
I confirm that all communications in relation to dealing instructions should be directed to my investment adviser.
Please confirm on what basis you wish your investment adviser to be appointed, non-discretionary or discretionary, by ticking
the appropriate box below.
I confirm that my investment adviser will be acting on a non-discretionary basis. Dealing instructions may only be forwarded to
RL360 after my investment adviser has consulted me. My investment adviser has confirmed to me that they have the necessary
regulatory authorisations in order to perform this role. I understand that RL360 is not required to obtain proof that my
investment adviser has consulted with me, prior to acting on any instructions received.
I confirm that my investment adviser will be acting on a discretionary basis. Dealing instructions may be forwarded
to RL360 without my consent. My investment adviser has confirmed to me that they have the necessary regulatory
authorisations in order to perform this role.
I request the payment of an investment adviser charge from my plan. I authorise RL360 to pay the investment adviser charge to
my Investment adviser in line with the following:
Investment adviser charge
% per year, taken quarterly as a percentage of my plan value (the fee should not be more than 1.5% per year).
Note:
where this charge is used in conjunction with a financial adviser charge, the two charges combined cannot be more than
2.0% per year.
The charge will commence from the date we receive your completed form. It will be calculated and paid each quarter from the
plan anniversary.
15 PIMS APPLICATION FORM - LIFE ASSURANCE
SECTION 1 INVESTMENT ADVISER APPOINTMENT CONTINUED
I acknowledge that RL360 has the right to reject the appointment of my investment adviser at its discretion.
I am aware that for as long as I have an appointed investment adviser I will be unable to access online dealing facilities.
I confirm that should I wish to change my investment adviser, or bring this agreement to an end in the future, I agree to inform
RL360 in writing (originals only), immediately.
I acknowledge that RL360 has the right to reject the requested appointment of my investment adviser at its discretion.
I agree that I am solely responsible for the appointment of an investment adviser to my plan and that I am also responsible for
ensuring that they have the appropriate experience, and/or qualifications and permissions to provide me with investment advice.
I acknowledge that RL360 is not liable for the performance or conduct of my investment adviser, or for ensuring that they hold
and continue to maintain any regulatory or legal permissions required to provide investment advice.
Applicant 1 Applicant 2
Signed
Full name
Date (dd/mm/yyyy)
SECTION 2 INVESTMENT ADVISER DETAILS AND CONDITIONS
Investment adviser to complete
Full name
Online services username
(if registered)
Company name
RL360 adviser number
Investment adviser
company address
Email address
Telephone number
Fax number
If you do not have Terms of Business with RL360, please contact your Regional Sales Manager before submitting this form.
In accepting the appointment of investment adviser to the above stated plan, I agree to the following terms and conditions:
1. All instructions relating to the purchase, sale or switching of assets will be in respect of the range agreed by RL360 as being
eligible for the plan.
2. All instructions should be provided in a format as agreed by RL360.
3. RL360 will purchase, sell or switch assets at the relevant market price as available at the time of placing an instruction.
4. RL360 has the right to accept or reject any instruction from the investment adviser at its own discretion.
5. The investment adviser must maintain such authorisation as is necessary to act as an investment adviser under the
legislation and regulation in the country in which advice is given.
6. RL360 and the plan owner cannot be held responsible for any future tax liability, that may accrue to the investment adviser,
as a result of a failure to levy tax where it later transpires that it should have been charged. The investment adviser is
responsible for deciding whether or not the service they are providing is subject to the levy of any additional taxes.
PIMS APPLICATION FORM - LIFE ASSURANCE 16
SECTION 2 INVESTMENT ADVISER DETAILS AND CONDITIONS CONTINUED
7. RL360 has the right to remove the investment adviser from the plan, without specifying a reason, and on giving one month’s
written notice to the plan owner and the investment adviser.
8. The investment adviser may resign their appointment by giving written notice to the plan owner and RL360. RL360 will
remove the investment adviser from the plan as soon as the notification is received.
9. The appointment will cease immediately upon written notification of bankruptcy, dissolution or insolvency of the investment
adviser, or any composition with creditors, or if the investment adviser is in breach of any regulatory requirement, or it
becomes illegal for the investment adviser to act in this capacity.
10. Where the appointment of the investment adviser ceases, the charge will also cease. Any charge accrued to the point where
the appointment ceases will be deducted from your plan and paid to the investment adviser. No further investment adviser
charge will be taken.
11. This appointment and agreement shall be subject to, and interpreted in, accordance with the laws of the Isle of Man.
12. RL360 will not be liable in the event that the appointed investment adviser or the plan owner fails to notify RL360 of any
material factor aecting the above.
Please submit a current certified copy of your company’s Authorised Signatory list with this form. If you have an additional list
for persons authorised to sign dealing instructions, please also submit a certified copy with this form.
Investment adviser
Signed
Date (dd/mm/yyyy)
www.rl360.com
HELPING YOU TO
PROTECT AND
GROW YOUR
WE A LTH
RL360 Insurance Company Limited
T +44 (0)1624 681681
E csc@rl360.com
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.
PML03c 06/21
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LIFE ASSURANCE (RL360)

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Completed 21 June 2021

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