Enhanced Pension Annuity Quotation Request Form

Please complete this form using black ink and capital letters

Home address:

Postcode:

Daytime telephone number:

Evening telephone number:

E-mail address:

Quote Reference No. (if applicable):

Source of quote:

Has Power of Attorney been vested in another party?

Yes No

If so which type?

Please ensure that all details entered are accurate to improve your benefits.

Have you been diagnosed with high blood pressure (hypertension)? Yes No

If yes, specify date of diagnosis:

If yes, specify last readings(s):

Date of reading(s):

Number and name(s) of medication(s) prescribed (excluding aspirin):

Have you been diagnosed with high cholesterol? Yes No

If yes, specify date of diagnosis:

If yes, specify last reading(s):

Date of reading(s):

Number and name(s) of medication(s) prescribed:

Medical Conditions

If you have ever been diagnosed with any of the following please only complete the relevant questionnaire(s).

Heart condition

Diabetes

Cancer, leukaemia, lymphoma, growth, or tumour

Stroke – please also complete the Activities of Daily Living questionnaire

Respiratory/lung disease

Multiple sclerosis – please also complete the Activities of Daily Living questionnaire

Neurological disease – please also complete the Activities of Daily Living questionnaire

Other Medical Conditions

For any conditions showing within the Medical Conditions area above, please complete the relevant questionnaire(s). For any other conditions, please complete the questions below (and, if relevant, the Activities of Daily Living questionnaire on page 13).

Condition 1 (Your details):

Condition 2 (Your details):

Condition 3 (Your details):

Condition 1 (Dependant details):

Condition 2 (Dependant details):

Condition 3 (Dependant details):

a. When were you first diagnosed with this condition?

Condition 1: Dependant:

Condition 2: Dependant:

Condition 3: Dependant:

b. When did you last experience symptoms for this condition?

Condition 1: Dependant:

Condition 2: Dependant:

Condition 3: Dependant:

c. When did you last receive medication/treatment for this condition?

Condition 1: Dependant:

Condition 2: Dependant:

Condition 3: Dependant:

d. When were you last admitted to hospital for this condition?

Condition 1: Dependant:

Condition 2: Dependant:

Condition 3: Dependant:

e. How many times have you been hospitalised for this condition? Please put a figure in the relevant box.

Condition 1:

Condition 2:

Condition 3:

f. Have you received any of the following treatments for this condition within the past 5 years? Please tick box.

None

Renal dialysis

Surgery

Please specify:

g. Your current medication

Medication 1:

Medication 2:

Medication 3:

Dependant’s current medication

Medication 1:

Medication 2:

Medication 3:

If you have a Financial Adviser, this section should be completed by them.

What was the basis of sale (please tick)

Advised – Independent

Advised – Restricted

Advised – Simplified

Non-Advised – Execution Only

Non-Advised – No Advice

Non-Advised – Direct Offer

Name of Firm:

Contact Name:

Company Address:

Postcode:

E-mail:

FSA Reference Number:

Telephone Number:

Facsimile Number:

Adviser Remuneration

a) Adviser Charge

Not to be facilitated by the annuity provider

Initial Adviser Charge facilitated by the annuity provider £ or %

Where should the Initial Adviser Charge be deducted from (please tick)?

Total purchase money

Purchase money after the payment of any Pension Commencement Lump Sum (tax free cash)

Pension Commencement Lump Sum (tax free cash)

On-going Adviser Charge facilitated by the annuity provider £ and or %

b) Commission (only available on Non-Advised Sales)

£ or %

Nil Commission

How would you prefer to receive the quote?

Post Fax Email

If you have a Financial Adviser, please ask them to assist you with the completion of this page.

Note: Not all of the life offices may offer these options, for example RPI escalation may only be available from certain offices. You will need to contact each office for more information. Please photocopy this page if you are requesting multiple quotes.

Total purchase price £ before payment of pension commencement lump sum (tax free cash):

£ net amount after payment of pension commencement lump sum (tax free cash):

Source of funds:

Name of ceding pension provider/s:

Pension Commencement Lump Sum (Tax Free Cash) required? Yes No

If yes, please give amount, if less than 25% £

Registered pension scheme Yes No

Death in service Yes No

Pensions credit Yes No

Assumed annuity commencement date:

Pension benefits £

If applicable GMP/related benefit

Pre 06/04/1988 Value £ Escalation rate % Revaluation rate %

Post 05/04/1988 Value £ Escalation rate % Revaluation rate %

Annuity options

Payable Yearly Half Yearly Quarterly Monthly

In advance In arrears

With proportion Without proportion

With overlap Without overlap

Escalation 3% 5% RPI LPI Other

Guarantee None 5 Years 10 Years (max) Other

Payable as lump sum, if possible Yes No

Value Protection % please specify the percentage of the annuity to be protected:

Value Protection (Joint Lives) Payment on spouse death Payment on annuitant’s death

With dependant’s benefit Yes No

% dependants benefit on death:

Ceasing on remarriage Yes No

Single life and joint life Yes No

Would you like Investment Linked Annuity quotations? Yes No

If yes, please state the level of return to be assumed:

For unit linked products, please state the % benchmark:

Number of illustrations expected:

This assumes that the annuitant’s fund is within the lifetime allowance.

If above LTA, please state the level of protection:

Notes: