Executive Pension Provider Installation pack for a single member plan

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Executive Pension Provider OFFICE USE ONLY Contract type:Policy/Contract number:Client number:Intermediary:Agent/Agency No.: SECTION 1 EMPLOYER 9S DETAILS Name of employer: Nature of trade, occupation or business:Company registration number: Employer tax district number:Names of the directors of the Company: Employer tax reference number: Business Address: Registered Address: (If different from business address) SECTION 2 EMPLOYEE 9S DETAILS Mr.Mrs.Ms.Place of birth: Surname:Date of birth:Age next birthday: First name(s):Marital Status: Country ofresidence: Home Tel. No:Mobile. No: E-mail address: PPS No: Date of entry into service:Date of entry to plan: Selected retirement age Remuneration (see notes below) (a) Basic Salary (per annum) (b)Fluctuating emoluments per annum (averaged over the last 3 years) Notes: (For Section 2.) (a)Directors 9fees can be treated as remuneration only if: (i)the director is beneficially entitled to the fees and any other remuneration and is not under an obligation to account for t hem to another company or employer; and (ii)the fees and other remuneration arenot being treated for tax purposes as a receipt of a profession in which the director is engaged.If these conditions are not applicable the amount of director 9s fees should be omitted.If included, directors 9fees may rank as either basic salary or fluctuating emol uments, according ... more. less.

to the basis on which they are voted. (b)Final remuneration for a 20% director is based on the average of total emoluments for any three or more consecutive years en ding not earlier than 10 years before the normal retirement date. If this application is in respect of such a director who is within 3 years of the selected retirement age, the basic salary shown above should be averaged over at least 3 years (or such shorter time as he/she has been in the service of the Employer). (c)A 820% director 9is one who, either alone or together with his/her spouse and minor children, is or becomes or at any time wit hin 3 years of the specified normal retirement date, or earlier retirement, or leaving service was the beneficial owner of shares which, when added to any shares held by the trustees of any settlement to which the director of his/her spouse had transferred assets, carry more than 20% of the voting rights in the company providing the benefi ts or in a company which controls that company. (between 60 and 70 yrs) Address: AF101 Oct 2007 SECTION 3 DETAILS OF CONTRIBUTIONS (FOR PENSION AND DEATH IN SERVICE BENEFITS) Amount of employer 9s Amount of employer 9s regular contribution:single contribution: Amount of employee 9s Amount of employee 9s Payable: Annually: ordinary regular contribution:single contribution: Regular additional contribution:Monthly: Fund(s) to which contributions are to be allocated (whole percentages only). Please make sure the percentages you have given add up to 100. Note: must be a minimum of 10% per fund. Please consult your Account executive to ensure that your chosen Funds are available on your chosen product Installation pack for a single member plan Are vested rights required from outset:Yes:No Is the employee a 5% director?Yes:No Is the employee a 20% director?Yes:No (see notes below) Fund%Fund%Fund% ManagedEuropean Corporate BondGlobal Ventures Property Managed GrowthEuropean Long BondIrish Commercial Property With ProfitIndex LinkedUK Select Property ConsensusCashKBC Euroland High Yield Equity Irish EquityKBCAM ManagedKBC Global High Yield Equity European EquityBalanced Investment SolutionInsight Currency International EquityStewardship (Ethical)Magnet Explorer Fixed InterestNew Ireland ManagedMagnet Portfolio Benefits requiredSum insured per annum Type of Cover required? Level Premium/Benefit or Premium/Benefits Indexed at 3% or Premium Level/Benefit in payment Escalating at either 3% or 5% (% must be chosen when selecting this option) Deferred period:13 weeks26 weeks52 weeksCeasing at age:556065 Is premium protection required for:Employer contribution:Yes:No:Employee contribution:Yes:No: If 8Yes 9, please indicate contribution cover:Employer cover:Employee cover: Type of Premium:GuaranteedReviewable SECTION 4 BENEFITS ON DEATH IN SERVICE (COMPLETE ONLY IF REQUIRED, TOGETHER WITH SECTION 3 ) Is the life cover to be: (a) associated with your Pension Plan (with the cost met by unit cancellation)?Yes:No: Sum assuredIncluding the value of the fund: Excluding the value of the fund: or (b) aseparate Term Assurance policy (at an additional cost)?Yes:No: If 8Yes 9, please state: Sum Assured orPremium payable annually: or monthly: SECTION 5 INCOME PROTECTION INSURANCE (COMPLETED ONLY IF REQUIRED, TOGETHER WITH SECTION 3 ) What is your occupation?Type of business you work in: Salary:Are you self-employed or a share-holding director?Yes:No: If 'Yes', for how long?Years:Months:Number of employees working for you (including sub-contractors) if applicable? If you were unable to drive could you still carry out your current occupation?Yes:No: SECTION 6 DETAILS OF YOUR OCCUPATION if you answer yes to any question please give details in the space provided at the end of the form p.m. Are any of the following an important part of your job or working environment? (Please tick if yes and give details at back of form.) Travel abroad/offshoreWorking in extreme temperaturesWorking at heightsManual/Physical Activity Working at depthsUsing Machinery ToolsOther (Please specify) " SECTION 7 HEALTH DETAILS- if Death in Service and /or Income Protection Insurance benefits are required. If you answer 8yes 9to any of the questions below, please give details in space provided at end of form " YesNo 1 a)Have you consulted a doctor or required medical supervision for any of the following: colds and flu, food poisoning, operations (tonsils, ingrown toenails, appendix, vasectomy), acne, childhood illnesses (mumps, measles, chicken pox), sinusitis or verruca? b)For reasons other than those listed in Question 1 a): Have you, within the last five years, consulted anyone, for example: doctors, hospitals, clinics, counsellors or osteopaths about your physical or mental health. Are you taking any medicine or drugs, (whether or not prescribed byamedical practitioner) or receiving any treatment? c)Have either of your parents, or any brother or sisters, died or suffered from heart disease, a stroke, diabetes, high blood pressure, kidney disease, cancer, multiple sclerosis, nervous disorder, or any hereditary disease such as Huntington's disease beforeage 65. If yes - please give details i.e. which family member & age at diagnosis. (If cancer, please advise the location of same). d)Have you ever tested positive for HIV/AIDs, Hepatitis B or C or haveyou been tested/treated for any other sexually transmitteddisease, or areyou awaiting the results of such tests? 2 Have you ever suffered from; a)Depression, insomnia, exhaustion, an alcohol problem, anxiety state, nervous breakdown? b)Stress, chronic fatigue or other nervous or mental disorder? c) Epilepsy, fits, blackouts, giddiness or migraine? d)Bronchitis, asthma, pneumonia, pleurisy, tuberculosis or any other affection of your lungs? e)Backache or disc problem, any muscular,rheumatic, bony orother joint problem? YesNo f)Fainting, palpitation, undue shortness of breath, chest pain, rheumatic fever, raised blood pressure or other affection of your heart or circulatory system? g) Persistent or recurrent indigestion, ulcer (gastric or duodenal), gallstones or any disease of your stomach, bowels or liver? h)Any problems with your kidneys or bladder? i)Diabetes or any abnormality of your urine e.g., the presence of sugar,albumin or blood? j)Varicose veins, piles or hernia? k)Any problems with your eyes 0r vision (not wholly corrected by spectacles)? l)Any problems with your ears, hearing or balance? m)Any surgical operations? n)Psoriasis, eczema or dermatitis? o)Lumps, bumps or moles or any other skin problem? p) Multiple Sclerosis, tremor, loss of power or tingling in any of your limbs? 3 a)Please indicate if you currently have a GP In the event of Friends First needing to refer you to a doctor for an independent medical examination, please advise a convenient location and we will do our best to facilitate you. Name of doctor: Address: PAYMENTOF CONTRIBUTIONS INSTRUCTION TO YOUR BANK/ BUILDING SOCIETY TO PAY DIRECTDEBITS (for completion also, if income protection insurance is required) Your signature(s): 990457 1. The Manager: (Full address of your bank/building society in capitals) Please complete parts 1-4 to instruct your bank/building society to make payments directly from your account. Then return the form to Friends First, Friends First House, Cherrywood Business Park, Loughlinstown, Dublin 18. Originator's identification number: Originator's reference: (maximum 18 characters) 2. Name of account holder: Surname:Initials: Banks/Building Societies may decline to accept instructions to pay direct debits from some types of accounts. 3. Sort code: Account number: 4. Your instruction to the bank/building society: Iinstruct you to pay direct debits from my account at the request of Friends First Life Assurance Company Limited. The amounts arevariable and may be debited on various dates. Iunderstand that Friends First Life Assurance Company Limited may change the amounts and dates only after giving me prior notice. Ishall inform the bank/building society in writing if I wish to cancel this instruction. Iunderstand that if any direct debit is paid which breaks the terms of the instruction, the bank/building society will make a refund. Date: INSTRUCTION TO YOUR BANK/ BUILDING SOCIETY TO PAY DIRECTDEBITS (For Executive/Additional Pensions Provider) Your signature(s): 990457 1. The Manager: (Full address of your bank/building society in capitals) Please complete parts 1-4 to instruct your bank/building society to make payments directly from your account. Then return the form to Friends First, Friends First House, Cherrywood Business Park, Loughlinstown, Dublin 18. Originator's identification number: Originator's reference: (maximum 18 characters) 2. Name of account holder: Surname:Initials: Banks/Building Societies may decline to accept instructions to pay direct debits from some types of accounts. 3. Sort code: Account number: 4. Your instruction to the bank/building society: Iinstruct you to pay direct debits from my account at the request of Friends First Life Assurance Company Limited. The amounts are variable and may be debited on various dates. Iunderstand that Friends First Life Assurance Company Limited may change the amounts and dates only after giving me prior notice. Ishall inform the bank/building society in writing if I wish to cancel this instruction. Iunderstand that if any direct debit is paid which breaks the terms of the instruction, the bank/building society will make a refund. Date: Please provide details of benefits provided under any other scheme(s) including self-employed retirement annuity contracts as f ollows:Please enter 8nil 9 if no benefits are provided. Normal retirement date: Members pensionSpouses 9pension: Pension increases (if any): Death in Services Benefits: Revenue reference number: Former Employers name: Note: If it is not possible to provide all the information requested, please give full details of the arrangements including sc heme name, insurance company and policy number(s). The benefits shown above should include any benefits promised under a contract of service which are not being funded orinsured and any self-employed retirement annuity which does not relate to a concurrent employment. SECTION 8 BENEFITS FROM OTHER SCHEMES b)Your height (without shoes) ftins Your weight (in indoor clothes) stlbs YesNo c)Have you smoked any cigarettes, cigars, pipes or tobacco in the last 12 months? If 8yes 9, how many per day? d)Do you drink alcohol? If 8yes 9, how many units per week? (1 unit = 1 glass of wine / lager / 1 measure of spirit) If 8no 9when did you last drink? e)Have you ever been treated for alcohol abuse, or been advised by a doctor to cease or reduce your alcohol consumption or taken drugs other than for medical reasons? 4 a)Do you, or do you intend to engage in hazardous sports, pastimes or occupations of any kind e.g. Mountaineering, motor sports, diving, equestrian or aviation (other then as afare paying passenger), specialist employment such as building? (Please specify below) b)Do you intend to travel, work or reside outside the Republic of Ireland (excluding holidays)? (Please indicate below where you will be travelling to.) 5 Have you ever been declined, postponed or accepted on special terms by Friends First or any other insurer for life, critical illness or permanent health insurance? Please give details of the company and sum assured SECTION 7 HEALTH DETAILS CON 9TD per day per week To provide additional information more space is provided at the end of the form. Friends First Life Assurance Company Limited, Friends First House, Cherrywood Business Park, Loughlinstown, Dublin 18. www.friendsfirst.ie Friends First Life Assurance Company Limited is regulated by the Financial Regulator. Friends First is partof the Eureko Group. Please use this space to tell us any other relevant information or special instructions about your policy. OTHER DETAILS QUESTION NO. The Employer A.requests Friends First Life Assurance Company Limited (Friends First) to issue a policy or policies subject to the conditions prescribed by Friends First which are to be set out therein for the provision of benefits corresponding to those provided in the above mentio ned plan for members thereof and, B.agrees to pay or procure payment of all premiums as set out in the policy or policies, and C.declares that to the best of our knowledge and belief the statements made in the above application are true and complete and that this declaration and the information to be given as to the relevant particulars of the member involved and any subsequent declaratio ns shall be the basis of the policy or policies to be effected with Friends First and that any statement made to Friends First or a Medical Off icer of Friends First by amember in respect of whom a benefit is to be assured shall as regards such benefit, also be the basis of the policy or policie s and, D.declares that, to the best of our knowledge and belief, the participants provided herein are correct. Date: Ihereby apply to join the scheme, agree to be bound by the Rules, and authorise the deduction from my salary of any contributio n to be made by me in accordance with those Rules. I submit this application form with a view to entering into a contract or contracts for the benefi ts set out overleaf on Friends First Life Assurance Company Limited 9s (Friends First) normal terms and conditions (whichI am aware are available on request). Ihave read over the replies to all the questions in this application and declare that, to the best of my knowledge and belief, all information given is true and includes all material facts. I consent to Friends First seeking medical information from any doctor who has attended me concern ing anything that affects my physical or mental health or seeking information from any insurance office to which an application has been made for an insuran ce on my life and I authorise the giving of such information. I understand that in the event of my being medically examined the answers given by me to the me dical examiner acting on behalf of Friends First life shall be deemed to be incorporated in this application. Iconsent to Friends First seeking information and benefit details from the Administrator/Trustees (and/or relevant insurance of fice) of any scheme, arrangement or contract of which I am or have been a member and I authorise the giving of such information and details. I under stand that the contract or contracts will commence on the acceptance of this application byFriendsFirst Life Assurance Company Limited on its normal te rms and conditions unless I have given instructions to the contrary. Ihereby give my consent to the use and recording of my personal details (contained herein) by both electronic and printed means to Friends First Holdings Limited. IUNDERSTAND THATFRIENDS FIRSTLIFE ASSURANCE COMPANYLIMITED MUSTBE NOTIFIED OF ANYCHANGES IN MYHEALTH AND/OR CIRCUMSTANCES PRIOR TO THE ASSUMPTION OF RISK. Date: SECTION 9 EMPLOYER 9S DECLARATION Signature For and on behalf of (name of employer) SECTION 10 EMPLOYEE 9S DECLARATION Employee 9s Signature Letter of Exchange To: Dear("the Employer") has decided to establish with effect from ("the Commencing Date") a Retirement Benefits Plan to be known as the Retirement & Death Benefits Plan ("The Plan") for ("Members Name") to provide you with retirement benefits. The Plan is governed by this Letter and Rules ("The Rules"); you will receive a copy. The benefits under the Plan will be secured by a policy or Policies issued by Friends First Life Assurance Company Limited ("Fr iends First") in accordance with the declarations made in the application form(s) to which this Letter is attached and any additional declarations made to Friends First for the purposes of this Plan. The Policy or Policies issued by Friends First will be held by the Employer (if corporate body) or byand and (if non-corporate body) as Trustee(s) of the Plan for payment of the benefits in accordance with the Rules. The Premiums payable towards the provision of the benefits under the Plan will be contributions m ade by you and/or the Employer in accordance with the declaration(s), subject always to the Rules. The Employer now establishes the Plan under irrevocable trusts to be administered in accordance with the Rules, being a retirem ent benefit plan capable of being approved by the Revenue Commissioners as an exempt approved plan under Part 30 Chapter 1 of the Taxes Consolidation Act 1 997 providing you with relevant benefits as defined in the Section 770 of the Taxes Consolidation Act 1997. Please acknowledge acceptance of this Letter and of the Rules bysigning belowand returning this Letter to the Employer. Yours sincerely, SIGNATURE FOR THE EMPLOYER NAME IN BLOCK CAPITALS Iagree to the Terms and Conditions of this Letter and attached Rules. Date SIGNATURE OF MEMBER NAME IN BLOCK CAPITALS We the Trustees of the Plan appointed in this Letter of Exchange hereby consent to act as Trustees. Date: Date: Date: TRUSTEES OF THE PLAN DATE STATUS Declaration of Trust This declaration of trust is made the whose registered office is situated at: (hereinafter called 8the Principal Employer 9which expression includes any corporate body person of firm which as a result of an y amalgamation or reconstruction or otherwise may carry on or succeed to the business of the Principal Employer). and whose registered office is situated at: (hereinafter called 8the Trustees 9which expression includes the Trustee or Trustees for the time being or the survivor or survi vors of them or the successor or successors of them in title or any trustee or trustees replacing the Trustees). Whereas A. The Principal Employer desires to inaugurate a scheme (hereinafter called 8the scheme 9) for providing relevant benefits as defi ned in Section 770 of the Taxes Consolidation Act 1997 in accordance with rules (hereinafter called 8the Rules 9) annexed hereto for and in respect of cer tain employees and where applicable directors (hereinafter called 8Members 9) of the Principal Employer and its subsidiaries and of any company or firm which is an associated employer as defined in the Rules (hereinafter called 8Associated Employer 9). B. The Trustees have been nominated by the Principal Employer and have agreed to act as trustees of the Scheme. C. The Trustees have effected, or are about to effect, certain assurances (hereinafter called 8the Assurances 9) on the lives of me mbers for the purpose of providing the said benefits. Now it is hereby witnessed and declared as follows: 1. The Principal Employer hereby inaugurates under irrevocable trusts with the effect from the the scheme which shall be known as the Retirement and Death Benefits Scheme for the Principle Employer. 2. The Principal Employer herebyappoints the Trustees to be trustees of the scheme to hold the policy or policies providing the As surances on trust for the purposes of the scheme in accordance with this deed and the Rules. 3. The Trustees hereby undertake and declare that they will pay or procure payment from the Principal Employer and any subsidiary or any Associated Employer of the premiums payable from time to time under the Assurances. 4. The Principal Employer hereby covenants with the Trustees that they will be bound by such provisions of the Scheme as shall ap ply to the Principal Employer. 5 .The Administrator of the scheme as required under Part30 Chapter 1 Taxes Consolidation Act 1997 shall be the Trustees. 6. The power of removing or appointing Trustees of the scheme shall be vested in the Principal Employer and the Principal Employer may, by deed, removeand/or appoint any Trustee provided always that there shall not at any time be less than two trustees unless a corporatio n is appointed as a trustee. 7. The scheme shall be terminated and the trusts of the Plan shall cease and determine in accordance with the provision of the Rul es. In Witness Whereof these presents have been entered into the day and year first above written. The Common Seal of the Principal Employer was hereunto affixed in the presence of Signed Sealed and Delivered on behalf of the Trustees in the presence of Signed Sealed and Delivered on behalf of the Trustees in the presence of day ofyear day ofyear by Director Director Witness Secretary Witness Secretary C.S.

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