Broker Individual PRSA Application - New Ireland Assurance

Broker Individual PRSAApplicationPensionsPlease tick (✔) one box only: Online applicationPaper applicationPlease complete in block capitals and tick (✓) where appropriate.1. Personal DetailsTitle: Mr. Mrs. Ms. Other Telephone: HomeFirst Name:Surname:WorkMobileAddress:Email:Occupation:Salary/Remuneration: _ p.a.Sex: Male Female PPS Number: –Date of Birth:D D M M Y Y Y YChosen Retirement Age:Marital Status: Single Married Separated Date of Joining Employer :D D M M Y Y Y YDivorced Widowed OtherCivil PartnershipPlease indicate which one of the following best describes your occupation status:Employee:Manager, professional, technical and administrativeClerical and secretarialTrade, craft and relatedPersonal and protective serviceSalesPlant and machine operativeOther employeeORSelf Employed:AgriculturalOther Self-EmployedORNot Economically Active/UnemployedNote: If you are a member of an Occupational Pension Scheme you must take out an AVC PRSA to be eligible to apply for income tax relief.Page 1 of 8

2. Evidence of Age and PPS numberEvidence of Age (where required)Original Document seen (Tick as appropriate):Driving Licence Passport Birth CertificateRef. No of DocumentEvidence of PPS numberOriginal Document seen (Tick as appropriate):P60 P45 P21 Balancing StatementTax Free Allowance CertPayslipOther (please specify)3. PRSA Plan DetailsPlan Type: Standard PRSA or PRSA Plus (Non-Standard PRSA)Payment Method: Direct Debit or Cheque (Annual only)Commencement Date:D D M M Y Y Y YRegular PRSA Contribution: _ per month quarterly half-yearly annuallyInflation related Regular PRSA Contribution increases (minimum 5% per annum) will apply.If not required, please tick here(Not applicable if payroll deduction applies).A Single PRSA contribution may be paid by cheque or other payment method as agreed by New Ireland.A Single PRSA contribution Only:Single PRSA Contribution:Transfer:__4. Investment Details100% of PRSA contributions will be invested in the Individual Retirement Investment Service (IRIS), the default investment strategy,unless otherwise stated.Regular PRSA ContributionSingle PRSA ContributionLifestyleIRIS (Default Investment Strategy) % %Consensus IRIS % %Low RiskPension Cash Fund % %Medium RiskPension Gilt Fund % %Medium to High RiskPension Consensus Fund % %Pension Managed Fund % %Pension Evergreen Fund % %KBI* Pension Managed Fund % %Income & Growth Fund % %Pension Ethical Managed Fund % %Page 2 of 8

4. Investment Details (Continued)High RiskGlobal Equity Fund % %Pension International Equity Fund % %*previously known as KBCAM Pension Managed FundIf you wish to invest in other funds through a PRSA Plus (Non-Standard PRSA) please specify below:% %% %% %% %% %Total 100% 100%5. Declaration of Receipt of Disclosure Information and Policy Replacement• Please complete this section before signing this PRSA application.I confirm that the insurance intermediary has provided me with:(Please tickappropriate box)(a)OR (b)A Preliminary Disclosure Certificate, incorporating clientspecific details and the number of this Certificate isA Preliminary Disclosure Certificate, incorporating sample details rather than details appropriate to me.Declaration under Article 3(5) of the Personal Retirement SavingsAccounts (Disclosure) Regulations 2002• WARNING: If you propose to enter into this PRSA contract in complete or partial replacement of an existingPRSA contract or a retirement annuity contract, please take special care to satisfy yourself that this PRSA contractmeets your needs. In particular, please make sure that you are aware of the financial consequences of replacingyour existing PRSA contract or retirement annuity contract. If you are in doubt about this, please contact yourPRSA provider.Declaration of PRSA Provider or IntermediaryI hereby declare that in accordance with Article 3 of the Personal Retirement Savings Accounts (Disclosure) Regulations 2002,a Preliminary Disclosure Certificate has been provided to the applicant and that I have advised the person concerned as to thefinancial consequences of replacing an existing PRSA contract or retirement annuity contract with this PRSA contract bycancellation or reduction and of possible financial loss as a result of such a replacement.SIGNHEREInsurer/IntermediarySignature:Date:D D M M Y Y Y YDeclaration of ApplicantI confirm that I have received in writing the information specified in the above declaration.SIGNHEREApplicant Signature:Date:D D M M Y Y Y YPage 3 of 8

6. Declarations/Data Protection Consent1. I have read and understand the replies to all the questions in this application (irrespective of whether the application is being madeonline or otherwise) and declare that all statements made by me or written at my request are true and complete and shall be thebasis of the proposed contract.2. I apply for a PRSA policy. I confirm my agreement to pay Regular and/or Single PRSA contributions as described in this application.I have been provided with a copy of a PRSA Brochure and the charges for the PRSA I am applying for have been explained to me.3. I confirm that I have received the Central Bank of Ireland’s Fact Sheet on PRSAs.4. I understand that any changes to the statements in this application before the proposed contract comes into force must benotified to New Ireland.5. I understand that where I have agreed to pay by direct debit, and upon completion of the direct debit mandate, premiums will not becollected from my account for a minimum of 3 days.6. I understand and accept that unless I have indicated to the contrary in Section 3 of this application that my Regular PRSAcontributions will increase each year to take account of inflation. This provision will not apply if my contributions are paid by payrolldeduction.The “Data Controller” for the purposes of the Data Protection Acts 1988-2003 is New Ireland Assurance Company plc (New Ireland). Thepersonal data being collected on this form is for the purposes of processing your application and may be disclosed in accordance withand to other parties as identified and consented to in the paragraphs below.“Information” means any information including medical and non-medical given by me or on my behalf in connection with this applicationor any further information which may be given at a later stage either in writing, by email, at a meeting or over the telephone.“Marketing” means direct marketing and cross-selling of the services and/or products provided by New Ireland or arranged by NewIreland with a third party.I understand and consent that New Ireland and its duly authorised agents may:• contact me by phone or by letter in relation to the administration (including any contractual review) of the contract;• hold and use the Information on computer file, in any other dematerialised form or in written hard copy on its own behalf and may useor pass the Information to third parties for administration, regulatory, customer care and service purposes;• disclose and/or transfer my Information to other countries for any of the purposes specified, to persons who have beenapproved by New Ireland and in a manner compliant with applicable data protection legislation;• use my Information to carry out statistical analysis and market research.I agree that New Ireland or a duly authorised agent of New Ireland may contact me in person, by phone, letter,e-mail or other electronic means if it considers that my financial planning arrangements need to be reviewed,my level of cover needs to be revised, and/or to provide me with general information relating to the contract bye-mail or other electronic means with New Ireland at any time.YesI agree that the Information may be held and used by New Ireland for Marketing purposes, including Marketingby e-mail or other electronic means.YesI understand that I may write to advise New Ireland to cease to hold and use the Information for Marketing purposes at any time.NoNoSIGNHEREApplicant Signature:Date:D D M M Y Y Y YPage 4 of 8

Comhlucht Na hÉireann um Árachas c.p.t.New Ireland Assurance Company plc.11-12 Dawson Street, Dublin 2.7. SEPA direct debit mandatePolicy numberPlease return to:Comhlucht Na hÉireann um Árachas c.p.t.New Ireland Assurance Company plc., 11-12 Dawson Street, Dublin 2.Creditor identifierI E 3 0 N I A 9 9 9 3 6 8Account number (IBAN)Swift BICAccount holder name(s)Account holder addressType of payment✔ RecurrentAccount holdersignature(s)By signing this mandate form, “you authorise (A) New Ireland Assurance Company plc to send instructions to your bank to debityour account and (B) your Bank to debit your account in accordance with the instruction from New Ireland Assurance Companyplc. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with yourbank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explainedin a statement that you can obtain from your bank”.Date of signingD D M M Y Y Y YCreditor use onlyUnique mandate referencePage 5 of 8

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8. To be completed by the Insurance IntermediaryName:Agency No.:Broker Contact Name:Broker Consultant’s:Name/No.:I enclose the following:Disclosure Declaration signed Yes NoContact Referral Yes NoOriginal Factfind Yes NoCharge detailsInitial Or FlatRenewalPlease choose which one of the following charging structures (shown in the format: (premium charge, management charge)) is to apply:Note: Any policies with a monthly premium of less than e200 will automatically be invested in the (5/3,1) product.Standard PRSANon-Standard PRSA(5,1) (5,1)(4,1) (4,1)(3,1) (3,1)(2,1) (2,1)(1,1) (1,1)(0,1) (0,1)(2,1.25)(2,1.5)(0,1.25)(0,1.5)Note: The management charges listed are those for standard rate funds. Any excess management charges (eg. for Elements,Trilogy II, Innovator, BNY Mellon Global Real Return Fund, etc.) will apply in addition to this.Page 7 of 8

New Ireland Assurance Company plc.,11-12 Dawson Street, Dublin 2.T: (01) 617 2000 F: (01) 617 2075.E: info@newireland.ie W: www.newireland.ieNew Ireland Assurance Company plc is regulated by the Central Bank of Ireland. A member of Bank of Ireland Group.300758 V9.10.13Page 8 of 8