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LIFEPLAN (RL360)

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LIFEPLAN
APPLICATION
FORM
LIFEPLAN
TABLE
OF
CONTENTS
01
PAGE 1
YOUR DETAILS
02
PAGE 2
LIVES ASSURED
03
PAGE 4
PLAN REQUIREMENTS
04
PAGE 4
PAYMENT DETAILS
05
PAGE 4
CHOICE OF FUNDS
06
PAGE 5
LIFESTYLE DETAILS
07
PAGE 7
MEDICAL QUESTIONS
08
PAGE 9
ADDITIONAL INFORMATION
09
PAGE 10
IMPORTANT NOTES
10
PAGE 10
DECLARATION
11
PAGE 12
FINANCIAL ADVISER DETAILS
12
PAGE 13
APPLICATION CHECKLIST
13
PAGE 15
NOMINATION OF BENEFICIARIES
14
PAGE 18
PAYMENT METHODS
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 12 - Application Checklist before submitting your application, to make sure that you
provide us with everything we need to process your application.
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.
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.
Once you have completed and signed the application you should send it along with all requested additional information to our 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 additional
information where required.
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.
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.
1 LIFEPLAN APPLICATION FORM
01 YOUR DETAILS
Please indicate which life assured basis you require
Single life
Joint life first death
Joint life both death
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 (eg National Insurance Number, Social Security Number, resident registration number)
Are you a US Specified 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
LIFEPLAN APPLICATION FORM 2
01 YOUR DETAILS CONTINUED
Exact occupation and duties
What is your exact
occupation?
What is your
company name?
What is the nature of
your business?
Please state the applicants’ combined earned/unearned income from all sources including any bonuses.
Currency
This year Last year Previous year
Earned
Unearned
If you have stated annual unearned income please provide details.
02 LIVES ASSURED
There can be up to 2 lives assured on the plan.
If either applicant is to be a life assured, tick the appropriate box below and proceed to "Additional occupation details" on the
next page.
Applicant 1 is a life assured
Applicant 2 is a life assured
If the lives assured are dierent from the applicants please provide their details below.
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)
Current residential
address and
postcode (in full)
Country of residence
Telephone number
Email address
Nationality
Date of birth (dd/mm/yyyy)
Relationship to the applicant
3 LIFEPLAN APPLICATION FORM
02 LIVES ASSURED CONTINUED
Exact occupation and duties
What is your exact
occupation?
What is your
company name?
What is the nature of
your business?
Please provide details of each of the life assured’s earned/unearned income from all sources including any bonuses.
Currency
Earned This year This year
Last year Last year
Previous year Previous year
Unearned
If you have stated
annual unearned
income please
provide details.
Additional occupation details
Which of the following do you perform in the course of your work? (Please indicate the % spent in each, and ensure the total adds
up to 100%.)
Life assured 1 Life assured 2
a) Managerial, administration, clerical and meetings?
b) Skilled, technical, light manual and supervisory on a shop or factory floor?
c) Sales (shop/oce based), mobile sales, sales management or
sales assistance?
d) Manual skilled, light unskilled or factory work, including lifting?
e) Unskilled work, heavy manual or heavy lifting?
= 100% = 100%
How much work is carried out at home?
%
%
Do you work more than 16 hours per week?
Yes
No
Yes
No
Do you receive payment from any other occupation?
Yes
No
Yes
No
If yes, please state other occupation
All applicant(s) and each life assured must sign the Declaration in Section 10 and the following should be submitted to support
the application:
• Full true certified copy of a current passport or national identity card carrying a photograph for each applicant and life
assured.
• Documentary evidence of each applicant’s residential address (see Section 12 - Application Checklist for details).
LIFEPLAN APPLICATION FORM 4
03 PLAN REQUIREMENTS
Plan currency
GBP
USD
EUR
Life assured 1 Life assured 2
Amount of primary life cover required
Do you require term life cover?
Yes
No
Yes
No
If ‘yes’ please state the amount of benefit
required and for what length of time the
benefit is required (minimum 5 years,
years
years
maximum 61 years)
Do you require accidental death benefit?
Yes
No
Yes
No
(maximum age at entry 59 years attained)
04 PAYMENT DETAILS
Who will fund the plan ?
The applicant(s)
Employer
Spouse
Other
If the payer is anyone other than the applicant(s), please refer to Section 12 - Application Checklist, Third party payments for
further details.
Amount
Payment frequency
Monthly
Quarterly
Half-yearly
Yearly
Payment term
Whole life
Fixed term for
years
05 CHOICE OF FUNDS
Fund choice
Please list your choice of funds below, up to a maximum of five funds. Please ensure that the percentages invested total 100%
and that the amount invested in each fund is not below the GBP25/USD50/EUR50/CHF50/AUD50 minimum.
Please ensure that the percentages invested total 100%.
ISIN Fund name Currency Percentage
of payment
%
%
%
%
%
100%
5 LIFEPLAN APPLICATION FORM
06 LIFESTYLE DETAILS
Please note all questions must be answered in full, any questions answered with “N/A”, “-” or “/” are not acceptable. If you
answer yes to any question please provide additional information in
Section 08
.
Life assured 1 Life assured 2
6.1 Do you currently have an existing plan with us?
Yes
No
Yes
No
If yes, please insert your plan number in the appropriate box
6.2 Please state your height
cm
cm
feet
inches
feet
inches
6.3
Please state your current weight
pounds
pounds
kg
kg
6.4
In the past 12 months have you used tobacco products
Yes
No
Yes
No
(cigarettes, e-cigarettes, cigars or chewing)?
If yes, please state your daily consumption.
6.5 Is there any feature of your lifestyle, work or leisure
Yes
No
Yes
No
activities or any other circumstances or fact which
might aect or threaten your health or life expectancy?
If yes, please state full details in Section 08.
6.6
Do you intend to fly, other than as a fare paying
Yes
No
Yes
No
passenger on licensed commercial airlines or participate
in any hazardous pursuits? For example underwater
diving, motor racing? If yes, please complete the
supplementary Aviation Questionnaire or other
relevant pursuit questionnaire.
6.7
Will you be out of your stated country of residence for
Yes
No
Yes
No
30 days or more in any one year? If yes, please state
full details of countries to be visited, nature of visit and
length of stay in Section 08.
6.8
Do you expect or intend to seek a medical opinion within
Yes
No
Yes
No
the next 8 weeks? If yes, please state full details in
Section 08.
6.9
Has any insurer ever declined, postponed or accepted
Yes
No
Yes
No
an application on your life on special terms, or have you
withdrawn an application? If yes, please state the
company(ies), reason(s) and date(s) in Section 08.
6.10
Do you have any existing insurance policies (including
Yes
No
Yes
No
benefits with RL360 Insurance Company Limited) or are
you applying or expecting to apply for insurance benefits
with other companies, or do you intend to discontinue
any existing cover? Please state the total amount of life
and critical illness cover taken out on your life in the last
12 months, including reinstated policies, and the cover
currency in Section 08.
LIFEPLAN APPLICATION FORM 6
06 LIFESTYLE DETAILS CONTINUED
Current medical attendant (this section MUST be completed)
Please provide details of your usual medical attendant/attending physician below. If you have no usual medical attendant/
attending physician, please provide details of the last doctor you consulted and the reason.
Life assured 1 Life assured 2
Name of doctor
Number of years
attended
Address and
postcode (in full)
Country
Date of last visit (dd/mm/yyyy)
Reason for last visit
Results of last visit
If you require more space, please continue in
Section 08
- Additional information.
7 LIFEPLAN APPLICATION FORM
07 MEDICAL QUESTIONS
Please note all questions must be answered in full, any questions answered with “N/A”, “-” or “/” are not acceptable. If you
answer yes to any question please provide additional information in
Section 08
.
Life assured 1 Life assured 2
7.1 Have you ever been advised to give up tobacco
Yes
No
Yes
No
and/or alcohol for any specific reason?
7.2
Have either your drinking or tobacco habits diered
Yes
No
Yes
No
in the last five years?
7.3
Please state the specific amount of your average weekly
beer (in litres) beer (in litres)
consumption of alcohol (quantity and type).
wine (75cl bottles)
wine (75cl bottles)
spirits (measures) spirits (measures)
Do you have or have you ever had any of the following?
7.4 Heart or circulatory disorders e.g. high blood pressure,
Yes
No
Yes
No
stroke, chest pains, heart murmur, palpitations, rheumatic
fever, blood vessel disorders, elevated cholesterol?
7.5
Respiratory or lung trouble e.g. asthma, bronchitis,
Yes
No
Yes
No
persistent cough, tuberculosis?
7.6
Disorders of the digestive system, gall bladder or liver
Yes
No
Yes
No
e.g. duodenal ulcer, bleeding from the bowel, hepatitis?
Life assured 1 Life assured 2
7.7 Disease or disorder or infection of the kidneys, bladder or reproductive organs
Yes
No
Yes
No
e.g. protein or blood in the urine, stones, prostatitis, venereal disease, bilharzia?
7.8
Nervous, neurological or mental complaint e.g. fits, epilepsy, blackouts,
Yes
No
Yes
No
persistent headaches, paralysis, anxiety state, depression?
7.9
Ear, eye, nose, throat or skin disorders e.g. ear discharge, defective vision,
Yes
No
Yes
No
recurrent tonsillitis, porphyria, psoriasis, dermatitis?
7.10
Disorders or disease of muscles, bones, joints, limbs or spine e.g. rheumatism,
Yes
No
Yes
No
arthritis, gout, slipped disc, other back or neck troubles?
7.11
Diabetes, sugar in urine, blood or spleen disorders, thyroid or other
Yes
No
Yes
No
glandular disorders?
7.12
Cancer, leukaemia, tumour or growth of any kind?
Yes
No
Yes
No
7.13
Are any medicines or drugs currently prescribed for you, or are you receiving
Yes
No
Yes
No
any medical or psychiatric treatment or advice or awaiting surgery?
7.14
Have you received, or do you expect to receive, any advice, counselling,
Yes
No
Yes
No
treatment or blood tests in connection with AIDS, HIV or an HIV related
disorder or any sexually transmitted disease including hepatitis B?
7.15
Have you ever been counselled or treated in connection with alcohol or drugs?
Yes
No
Yes
No
LIFEPLAN APPLICATION FORM 8
07 MEDICAL QUESTIONS CONTINUED
7.16 Family history
Please provide details of your family history in the table below, including details of their current state of health or, if deceased,
the cause of death. Of particular importance is if your father, mother or any brothers or sisters have died or suered from
heart disease, stroke, kidney disease, cancer, multiple sclerosis or diabetes before the age of 65, or suered from any familial/
hereditary disorders.
Please tell us the age at outset if your relative had cancer and the part of the body first aected.
Life assured 1
Relatives State of health Age
(or if deceased please state cause of death)
(or age at death)
Father
Mother
Brothers
(numbers
born)
Sisters
(numbers
born)
Life assured 2
Relatives State of health Age
(or if deceased please state cause of death)
(or age at death)
Father
Mother
Brothers
(numbers
born)
Sisters
(numbers
born)
9 LIFEPLAN APPLICATION FORM
08 ADDITIONAL INFORMATION
Where any question(s) have been answered yes, or where further details are required to any answer(s) please provide as much
information as possible in the space provided below. Please state which question(s) the details relate to and, if applicable, which life
assured (first life assured and/or second life assured). If you require more space, please continue on a separate sheet.
Question
number
Life assured
(tick as appropriate)
Details
First Second
LIFEPLAN APPLICATION FORM 10
09 IMPORTANT NOTES
The answers provided on this form will be used to assess your application and you must, therefore, answer them fully and to the best
of your knowledge and belief. You must also give RL360 any other information which might be relevant and which could influence
the decision to accept your application. If you are unsure whether a particular fact is relevant, you should disclose it. Withholding
any relevant information may result in the forfeiture of your protection benefits even if your application has been formally accepted.
In such event, all monies paid may be forfeited. Please give careful consideration to the declaration before signing it.
Before the plan comes into force, any change of facts contained in the answers given must be notified to RL360 in writing. RL360
reserves the right to amend the terms on which your application may have been accepted or to withdraw acceptance in the event of
any such change.
Your application is not binding and no plan will exist until RL360 has issued a letter of acceptance, all conditions therein have
been complied with and your Plan Schedule has been issued.
Full details can be obtained by reading the LifePlan Terms and Conditions.
10  DECLARATION
For lives assured
10.1 I declare that I have read the important notes in Section 09 and that all statements made by me, whether in my handwriting
or not, are true and complete. I also declare that to the best of my knowledge and belief, I have disclosed all relevant
information concerning this application, whether or not covered by the questions in this application or any supplementary
questionnaires which might influence RL360’s decision to issue my plan.
10.2
I will disclose to RL360 any changes to the information given in this application which occur prior to the commencement of
the plan.
10.3
By signing below I irrevocably consent to RL360 seeking from any doctor, hospital, medical institution or other person,
information which may be related to my occupation, physical or mental health, including the result of any test, and I
authorise the giving of such information. This authorisation shall remain in force after my death.
For applicants
10.4 I agree that all statements, together with any forms, statements, reports or other information completed or supplied by me
or any party on my behalf, shall form the basis of the plan with RL360.
10.5 I have read the Product Guide and the Key Information Document and I'm aware of the charges that may be levied.
10.6 I agree to accept a plan in the form and containing the standard terms, conditions and rules ordinarily used by RL360 for
the type of benefits for which I have applied. In addition, RL360 shall not be bound in any way by any representations or
undertakings made or given by any person save as contained in the plan as issued. It is further agreed and understood
that, notwithstanding any statement made to the contrary by any person, no plan comes into existence and no liability
whatsoever will attach to RL360 as a result of this application unless and until the first payment has been received by RL360
and express written notice of acceptance of risk is issued by RL360.
10.7
To the best of my knowledge and belief I am not subject to any legislation that would make this application unlawful.
10.8 I confirm that on my own initiative I requested and received information about the plan from my financial adviser. On the basis
of that information, I hereby apply for this plan. I understand that the plan is oered by RL360 which is established in the Isle
of Man and as such is subject to the supervisory arrangements of the Isle of Man Government Financial Services Authority.
10.9 I understand that unless I provide a dierent address for correspondence in Section 01, all correspondence from RL360 shall
be sent to the first named applicant at the permanent address given for that applicant. I acknowledge that any person who
is advising me regarding the plan for which I am applying, is acting for me and not on behalf of RL360.
10.10
I will disclose to RL360 any changes to the information given in this application which occur prior to the commencement of
the plan.
11 LIFEPLAN APPLICATION FORM
10 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.
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 funds 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.
Key Information Document (KID)
I confirm that:
• I have included a signed KID with this application
• The details provided in the KID are the same as the details provided in this application
• I understand that if the details don’t match, a new signed KID containing the same information as my application will be
required before my plan can start
• 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.
Final agreement
I agree to the following documents forming the basis of the contract between me and RL360:
• this Application Form
• The Key Information Document
• My personal illustration
• 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)
LIFEPLAN APPLICATION FORM 12
10 DECLARATION CONTINUED
Applicant 1 Applicant 2
Signed
Date (dd/mm/yyyy)
Life Assured 1 Life Assured 2
Signed
Date (dd/mm/yyyy)
I give explicit consent to capture and process I give explicit consent to capture and process
my medical/lifestyle data my medical/lifestyle data
11 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)
13 LIFEPLAN APPLICATION FORM
12 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 and lives assured
Please send a suitably certified copy* of your passport or National Identity Card showing your photograph(s) and signature – 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:
Life assured 1 Life assured 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:
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 08 – 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.
Illustration and Key Information Document
Please make sure to include a signed Illustration and Key Information Document.
I have included a signed Key Information Document (please tick to confirm).
I have included a signed Illustration (please tick to confirm).
LIFEPLAN APPLICATION FORM 14
12 APPLICATION CHECKLIST CONTINUED
*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.
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 funding a plan for a partner:
•
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
15 LIFEPLAN APPLICATION FORM
13 NOMINATION OF BENEFICIARIES
In the event of the death of the life assured on whose death the benefits become payable, as specified in the plan schedule,
I hereby (jointly) appoint the beneficiary/ies named below to receive the benefits (represented by all rights to any proceeds
payable under the plan by reason of the death of the life assured) in the percentages stated below absolutely.
Beneficiary 1 Beneficiary 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)
Permanent address
and postcode
(in full)
Country
Date of birth (dd/mm/yyyy)
Country of birth
Nationality
Home telephone number
Mobile telephone number
Relationship to the applicant
Percentage of benefit
(whole numbers only)
%
%
Beneficiary 3 Beneficiary 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)
Permanent address
and postcode
(in full)
Country
Date of birth (dd/mm/yyyy)
Country of birth
Nationality
Home telephone number
Mobile telephone number
Relationship to the applicant
Percentage of benefit
(whole numbers only)
%
%
LIFEPLAN APPLICATION FORM 16
13 NOMINATION OF BENEFICIARIES CONTINUED
Beneficiary 5 Beneficiary 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)
Permanent address
and postcode
(in full)
Country
Date of birth (dd/mm/yyyy)
Country of birth
Nationality
Home telephone number
Mobile telephone number
Relationship to the applicant
Percentage of benefit
(whole numbers only)
%
%
Minor beneficiaries
Where any of the beneficiaries nominated herein has not attained the age of 18 years (notwithstanding that such individual may be
in accordance with the law of his or her domicile of full age and the expression ‘minor’ shall be construed accordingly) then I hereby
authorise RL360 in its absolute discretion, without seeing the application thereof, to pay the same to any parent or guardian of
such minor beneficiary or to apply the same in such manner as may be directed in writing by such parent or guardian and the
receipt by such parent or guardian in either case shall be sucient discharge to RL360 for any benefits so paid or applied.
Contingent beneficiaries
RL360 does not accept the nomination of contingent beneficiaries and in the event that any of the nominations above shall fail,
by reason of the death of a nominated beneficiary/ies before the death of the life assured the benefit payable on the death of
the life assured will be payable equally to the remaining beneficiary/ies. If at some point in the future you wish someone else to
benefit, a new Nomination of Beneficiary Form should be completed.
Important notes
If any of the nominated beneficiaries predeceases the life assured you are advised to review your appointment accordingly and,
if necessary, complete a new Nomination of Beneficiary Form.
This section must be completed by all applicant(s) who should sign in the presence of two independent witnesses who are not
themselves named as potential beneficiaries. One of these witnesses can be your financial adviser. You should all sign whilst together.
It is the responsibility of the applicant(s) to ensure that the nominated beneficiary/ies pursuant to this form will be eective
under his or her law of domicile and/or residence. A nomination will not restrict your right to assign the plan. However, any such
assignment will automatically revoke the nomination. The eect of the nomination is that upon the death of the life assured on
whose death the plan’s benefits become payable, those benefits shall be paid to the beneficiary/ies nominated. Where death
benefits become payable under a jointly owned plan, RL360 will require a signed form of discharge from both the surviving plan
owner and the nominated beneficiary/ies.
17 LIFEPLAN APPLICATION FORM
13 NOMINATION OF BENEFICIARIES CONTINUED
Declaration
I hereby declare:
• that the information given by me in this nominated beneficiaries section is true and complete
• that I have read and understood this nominated beneficiaries section and agree to be bound in accordance with its provisions
and in accordance with the LifePlan Terms and Conditions regarding the appointment of beneficiaries.
Date (dd/mm/yyyy)
Applicant 1 Applicant 2
Signature
(of applicant)
Witnessed by:
Signature
(of witness)
Print name
Address and
postcode (in full)
LIFEPLAN APPLICATION FORM 18
14 PAYMENT METHODS
You can make payments monthly or quarterly by credit/debit card, standing order or direct debit. If you prefer, you can make
payments on a half-yearly or yearly basis by credit/debit card, standing order, direct debit, telegraphic transfer or cheque.
Credit/debit card (please complete the credit card mandate on page 20)
Direct debit (GBP payments from UK and Channel Island banks only) (please complete the direct debit instruction on page 22)
Standing order (please complete the standing order instruction on page 24)
Cheque (half-yearly or yearly payment only) (please complete the banking details below)
Telegraphic transfer (half-yearly or yearly payment only) (please complete the banking details below)
Payments by cheque or 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
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.
Please note that GBP cheques can take up to five working days to clear. Other currency cheques may take considerably longer
to clear.
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 detailed above.
IMPORTANT:
some banking institutions may deduct charges for processing international payments. Please check with your bank
if any charges 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.
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
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
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.
19 LIFEPLAN APPLICATION FORM
LIFEPLAN APPLICATION FORM 20
CREDIT AND DEBIT
CARD MANDATE
Important
We are only able to accept cards with one of the logos above and prefixed with a ‘3’, a ‘4’ or a ‘5’.
The maximum amount that can be collected by credit card is GBP99,999.99 (or currency equivalent) per payment.
I authorise you, until further notice in writing, to collect payments as detailed below:
Currency GBP USD EUR
Payment amount in figures
Payment amount in words
Payment frequency
Monthly
Quarterly
Half-yearly
Yearly
Starting on (dd/mm/yyyy)*
* this applies to initial payment only, future payments are deducted
2 working days prior to the payment due date.
Card type Mastercard/Eurocard
Visa
JCB
American Express*
* The amount we collect from your card will be 1% higher than your payment amount to cover
additional charges applied by American Express.
Card issued by
(name of bank)
Country of card issuer
Cardholder’s name(s)
(must be an applicant)
Cardholder’s address
(as held by
the card issuer)
The cardholder’s address should be the same as that of the applicant(s). If it is not, please
provide reasons why in Section 08 – Additional Information.
Card number
- - -
Expiry date (mm–yy)
-
I understand that RL360 Insurance Company Limited (RL360) will advise me of the amount to be paid and the dates on which
payment is due and that RL360 may only change these after giving me prior notice.
I understand that this authority in favour of RL360 will remain in force until such time as I cancel it in writing.
Signature of
cardholder(s)
Date (dd/mm/yyyy)
LIFEPLAN
21 LIFEPLAN APPLICATION FORM
Additional information
In order to comply with the Isle of Man Insurance (Anti-Money Laundering) Regulations 2008, we may require additional source of
wealth evidence subject to where the bank that issued your credit or debit card is registered. For further information about country
tiers please refer to our source of wealth information document available online at www.rl360.com/sourceofwealth.pdf.
CREDIT CARD PRE-AUTHORISATION
Pre-authorisation is the process of pre-approving payments with the card provider. We carry out this process to make sure that the
card’s details are correct and working properly prior to collecting the payment.
This process will create a pre-authorisation on the credit card for one unit of the currency payments are made in i.e. GBP1.00/
USD1.00/EUR1.00 etc. This amount may not appear on the credit card statement, but will aect the card balance or spending limit
until the card provider removes it.
If the cardholder has opted to receive text messages, they may get a confirmation text for this transaction.
LIFEPLAN APPLICATION FORM 22
LIFEPLAN
DIRECT DEBIT
INSTRUCTION
Important
GBP payments from UK and Channel Island banks only.
Any changes to your payment will be applied without the need for a further instruction.
Service User Number
2 7 0 0 5 0
Name and full postal address of your bank or building society branch
To the manager
Bank/Building Society
Bank address
Name(s) of account holder(s)
Bank sort code
- -
Account number
Instruction to your bank or building society
Please pay RL360 Insurance Company Limited Direct Debits from the account detailed in this Instruction, subject to the
safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with RL360 Insurance Company
Limited and, if so, details will be passed electronically to my bank/building society.
Account holder 1 Account holder 2
Signed
Full name
Date (dd/mm/yyyy)
Banks and building societies may not accept Direct Debit instructions from some types of account
THE DIRECT DEBIT GUARANTEE
• This Guarantee is oered by all banks and building societies that accept instructions to pay Direct Debits
• If there are any changes to the amount, date or frequency of your Direct Debit, RL360 Insurance Company Limited will notify you 14
working days in advance of your account being debited or as otherwise agreed. If you request RL360 Insurance Company Limited to
collect a payment, confirmation of the amount and date will be given to you at the time of the request
• If an error is made in the payment of your Direct Debit by RL360 Insurance Company Limited or your bank or building society
you are entitled to a full and immediate refund of the amount paid from your bank or building society – If you receive a refund
you are not entitled to, you must pay it back when RL360 Insurance Company Limited asks you to.
• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be
required. Please also notify us.
This guarantee should be detached and retained by the payer.
23 LIFEPLAN APPLICATION FORM
LIFEPLAN APPLICATION FORM 24
STANDING ORDER
INSTRUCTION
Important
If you wish to change the amount you pay into your plan at a later date, you will need to complete a new standing order
instruction. If you wish to cancel your standing order you will need to do this directly through your bank.
To the manager
Bank/Building Society
Bank address
Plan reference
This reference number will be supplied by RL360 after receipt of the application and must be quoted by your bank on all
correspondence. Failure to do so may result in payment being rejected by our bankers.
Please debit the payment amount, together with any transfer charges, from my account detailed below:
Currency GBP USD EUR
Payment amount in figures
Payment amount in words
Payment frequency
Monthly
Quarterly
Half-yearly
Yearly
Payment start date
(dd/mm/yyyy)
Name(s) of account holder(s)
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)
LIFEPLAN
25 LIFEPLAN APPLICATION FORM
Please tick the box in the table below that matches your plan currency.
Tick one Currency SWIFT code IBAN Sort code Account
number
Bank name Account
name
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
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.
Account holder 1 Account holder 2
Signed
Full name
Date (dd/mm/yyyy)
LIFEPLAN APPLICATION FORM 26
27 LIFEPLAN APPLICATION FORM
LIFEPLAN APPLICATION FORM 28
www.rl360.com
PROTECTING YOU
WHEN LIFE DOESN’T
GO ACCORDING
TO PLAN
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.
LP05b 07/19
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Completed 21 June 2021

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