PENSIONBUILDER
CONTINUATION FORM
MEMBER APPLICATION
You should use this form if you have one of the following contracts:
Individual Personal Pensionbuilder
Company Personal Pensionbuilder
Please complete this application form if:
1. You have changed employer
2. You have become self-employed
3. You want to add regular contributions to a rebate only policy
4. You want to recommence regular contributions after a payment holiday
Please tick the appropriate box(es).
Please write in BLOCK CAPITALS and complete the relevant sections.
IMPORTANT:
Please ensure the declaration has been signed and dated.
WARNING: You must not make false statements when filling in this application; it is a serious offence.
The penalties are severe and you could be prosecuted.
If you have applied, or are considering applying, to HM Revenue & Customs for Enhanced Protection from any
potential lifetime allowance tax charge, such protection will be lost on any payment made to a pension plan
on or after 6 April 2006. For further information, please speak to a financial adviser.
Is this application being made through your employer?
Yes No If ‘Yes’, scheme name. A.ELIGIBILITY
NOTES
(1) Ordinary residence in the UK
generally means being resident
on a regular basis, i.e. year
after year. If you require further
information, please speak with
your financial adviser.
(2) If you tick this box, to be eligible
to join the Scottish Widows
Personal Pension Scheme, you
must have earnings chargeable
to UK tax in the tax year you
apply. Please note that
Scottish Widows can only accept
applications from individuals
who are ordinarily resident
in the United Kingdom, or in
a limited number of overseas
territories. Unless you are
habitually resident in the United
Kingdom, or in one of the other
territories referred to, we
will be unable to accept your
application. Please speak with
your financial adviser for
further details.
To be eligible for this plan you must be aged less than 75 and meet one of the following conditions.
Please tick whichever applies.
I am resident in the UK. (see note 1)
OR
I do not currently reside in the UK but I am a Crown Servant, or the husband, wife or registered
civil partner of a Crown Servant who has general earnings from overseas Crown employment.
OR
I am not a UK resident, but have earnings which are chargeable to UK income tax. (see note 2)
If you have been unable to tick any of the boxes above, you cannot pay contributions to this plan.
1
B. YOUR DETAILS
1. Your Title Mr Mrs Miss Ms Other (please specify)
2. Your Surname
3. Your First name(s)
(3) This should be your permanent
residential address. We will
send all correspondence to
this address. Please ensure
the postcode is provided.
4. Your address (see note 3)
Postcode
5.Country
6. Your Nationality
7. Your phone number (incl code)
(4) Sending personal information by
email is not secure. Only include
your email address if you agree
to Scottish Widows sending you
emails.
(5) A birth certificate should be sent
to us with your application. If
you have changed your surname,
for example, through marriage
or a registered civil partnership,
a copy of the appropriate
certificate should also be sent.
(6) If you have income from more
than one category, the category
that is your main source of
income will apply.
8. Your email address (see note 4)
9. Your date of birth (DD MM YYYY) (see note 5) 10.Are you: Male Female 11. Your marital status Single
Married / in a registered civil partnership
Separated
Divorced / registered civil partnership dissolved
Widowed / a surviving registered civil partner
12. Employment status (see note 6)
Are you:
Employed A pensioner If other, please indicate which of the following applies to you.
Are you:
Caring for one or more children aged under 16 Caring for a person aged 16 or over Self employed
Other
In full-time education
Unemployed
Other 13. If you are ‘Employed’, please give your employer’s name and address
Postcode
(7) Your National Insurance Number
can be found on a payslip or
P60, or on a tax return. If you
have a National Insurance
Number, it is essential that you
provide it, otherwise, we are
unable to accept contributions
and cannot process your
application. If you cannot find
your National Insurance Number
please phone the HM Revenue
& Customs General Enquiries –
0300 200 3500.
14. Your National Insurance Number (see note 7) 15. Your policy number
Z03 Please complete sections C or D and sections E, H and I as appropriate, and complete the Direct Debit
Mandate. Only complete sections F and G if your employer is paying the cost of life cover.
2
C. COMPLETE THIS PART ONLY IF YOU HAVE BECOME SELF-EMPLOYED
1. When did you become self-employed?
2. What net regular contribution do you wish to contribute?
£ 3. When do you wish to commence regular contributions? 4. If you wish to pay a single contribution please state the amount (a cheque must be sent) £ Once we have received the above information, we will collect regular contributions from your bank account.
D. COMPLETE THIS PART ONLY IF YOU HAVE CHANGED EMPLOYER
1. Your new employer’s name
2. Your new employer’s address Postcode
3. Your new employer’s telephone number (useful if there is a query)
4. Date you entered new employer’s service (DD MM YYYY)
5. Will your employer be paying a regular contribution to your personal pension?
6.Occupation
3
Yes
No
(8) The Money Purchase Annual Allowance (MPAA) is currently £4,000.
The MPAA applies to you if you have
flexibly accessed your pensions from
us or any other provider and have
received any of the payments listed
below from 6 April 2015 onwards:
• a payment from a flexible access
drawdown fund (also known as a
flexi-access drawdown fund);
• a payment from a capped drawdown fund which would exceed
existing capped drawdown limits;
• a pension encashment (also known
as an uncrystallised funds pension
lump sum);
• a payment under a flexible annuity
contract;
• a pension payment from a money
purchase scheme which has fewer
than 11 other pensioner members;
• a stand-alone lump sum from a
money purchase arrangement
where you were entitled to
primary protection with a right to
take a lump sum of greater than
£375,000.
The MPAA applies to all contributions
you pay (or that are paid on your
behalf e.g. employer contributions
and death-in-service premiums) each
year to all money purchase pension
schemes of which you are a member.
If the MPAA applies to you and your
contributions exceed it, you will be
liable to pay a tax charge based on
your highest rate of income tax. The
MPAA does not apply if you have
taken only –
• income from a capped drawdown
plan;
• tax-free cash (pension
commencement lump sums) when
using your plan to purchase an
annuity or drawdown plan; or
• “small pots” taken as a cash lump
sum.
In these circumstances, the higher
annual allowance applies to you.
(9) We will add basic rate tax relief to the
amount you pay. This figure includes
any payments made on your behalf by
anyone other than your employer. The
minimum you can pay is £16 net.
(10) This is the actual amount your
employer will pay to us. The minimum
your employer can
pay is £20 gross.
(11) Where this application is to pay
contributions through your employer’s
personal pension arrangement the
amount and payment date will be
set by them. To comply with the late
payment rules set by The Pensions
Regulator, payments which are made
through your employer’s bank account
must reach Scottish Widows by the
19th of the month following the
deduction from salary. For all other
cases please choose a payment date
up to the 28th of the month.
E.PAYMENTS
There is no maximum limit on how much can be paid to your plan, although we can only accept contributions
from you that are eligible for tax relief. Relief is available on contributions which don’t exceed your UK relevant
earnings, or £3,600 if higher.
The Treasury sets an annual allowance on the amount that can be paid into all your registered pension schemes
without incurring a tax charge. Your total contributions are further limited to the ‘Money Purchase Annual
Allowance’ if you have flexibly accessed a pension with us or any other provider. (See note 8)
Please speak to your financial adviser if you are unsure about how much you can pay.
Have you flexibly accessed any pensions with us or any other provider? (see note 8)
Yes
No
If ‘Yes’– Date of first payment (DD MM YYYY)
Regular payments
a) How do you want to pay regular payments? Monthly
b) How much do you want to pay? (see note 9)
Yearly
£ £ (NET of tax) or
% of salary (NET of tax)
c) How much is your employer to pay? (see note 10) £ (GROSS) or
% of salary (GROSS)
d) Salary £
£ e) When do you want to start paying? (DD MM YYYY)
(see note 11)
Regular payments are usually made by direct debit. To pay by direct debit please complete the attached
direct debit instruction. If you wish to pay using another method please contact us for more information.
REGULAR CONTRIBUTION DEDUCTION AUTHORISATION
If your employer will be deducting your contribution from your salary, you should sign this authorisation and
give it to your employer.
I authorise the deduction of the appropriate contribution from my salary.
Your name (in BLOCK CAPITALS)
Your signature
Date (DD MM YYYY)
4
F. DEATH BENEFITS – ONLY AVAILABLE TO POLICIES STARTED BEFORE 6 APRIL 2001
This is paid if you die before your Personal Pension Age. Fill in this section only if you want this benefit and
your employer will be paying the cost of it.
Regular payments
1. How much death benefit do you want?
2. Will your employer pay for this benefit?
3. Do you want the death benefit to be:
a) in addition to the cash value of your policy?
(The cost of this will be in addition to your regular contribution).
OR
£ The cash value paid on your death is explained in the Member’s Booklet you received when you took out this policy.
b) the higher of the cash value of your policy and the amount shown in 1.
(The cost of this will be taken from your regular contribution before it is invested).
If you have completed this section, please also complete section G.
5
Yes
✓
G. MEDICAL QUESTIONS
You should complete this section only if you have completed section F.
1. a) Are you already assured with Scottish Widows?
Yes
No
Yes
No
Yes
No
If ‘Yes’, please give policy number(s).
b)
c)
Have you ever withdrawn an application before the company
advised you of its decision?
Has any application on your life been declined,
deferred or offered on non-standard terms?
If ‘Yes’, please give details
d) Name, address and telephone number of your usual doctor (to whom reference may be made if desired).
If your doctor has changed during the past year state also the name, address and telephone number of
your previous doctor.
(12) This question must be answered
honestly and fully otherwise we
may not pay any claims, amend
the terms of the life cover or at
worst cancel the cover. Tobacco
products include cigarettes,
cigars, pipes and nicotine
replacements.
If you have disclosed that you
are a non-smoker, you may be
asked to take a sample test (e.g
saliva or urine test) to confirm
you are a non-smoker.
(13) This question must be answered
honestly and fully otherwise we
may not pay any claims, amend
the terms of the life cover or at
worst cancel the cover.
Beer – 1 pint = 2.5 units
Wine – 1 glass (175ml)
= 2.5 units
Spirits – 1 standard measures
(35ml) = 1.5 units
Usual doctor
Previous doctor
Name
Address
Postcode
Telephone number
2. a) In the last 12 months, have you smoked cigarettes,
a pipe or cigars, or used any other tobacco products
or nicotine replacement products? (see note 12)Yes
b) If you smoke cigarettes, how many on average do you smoke per day? c) Do you drink alcohol? (see note 13)Yes
d) Please state your average amount of alcohol units per week
3. a)
Have you attended or been advised to attend any hospital or
clinic for any advice, treatment, tests or investigations within
the last two years or are you currently receiving any medical
treatment or attention?
b) Have you had a positive test for HIV or Hepatitis B or C?
If ‘Yes’, please give details
6
No
No
Yes
No
Yes
No
G. MEDICAL QUESTIONS (CONT’D)
4. a) Have you ever had any disorder of the heart or circulation,
high blood pressure, stroke, diabetes or any form of cancer?
Yes
No
b) Have you ever had any mental or nervous systems disturbance,
multiple sclerosis or any respiratory, kidney, urinary, stomach
or bowel disorder?
Yes
No
c) Have you any intention of journeying abroad or living outside the
UK or have you done so within the last 12 months (excluding
holidays or business trips to North America or Europe)?
Yes
No
d) Have you any intention of participating in any hazardous
work or leisure activity (eg. flying, climbing, diving, working
at heights or motor sports)?
Yes
No
Yes
No
Yes
No
Yes
No
If ‘Yes’, please give details
5. a) In the last 12 months have you had any illness or injury which
has kept you off work for more than 2 weeks?
b) Do you have any handicap or disability which restricts or is likely
to restrict your ability to work?
If ‘Yes’, please give details
6. a) What is your height without shoes?
b) What is your weight in normal indoor clothing?
c) Do you do any physical/manual work?
If ‘Yes’, please give details
7
G. MEDICAL QUESTIONS (CONT’D)
7. Have any of your family – father, mother, brother(s), sister(s)
a) died? If so give relationship, cause and age at death.
Yes
No
b) suffered from cancer, diabetes, heart / kidney trouble, stroke,
nervous disorder or any hereditary or familial disorder?
Yes
No
If ‘Yes’, please give details
8
IMPORTANT NOTES
Important Note
In accordance with the Association of British Insurers’ policy on genetics and insurance, you do not need to
tell us about any genetic test result you have had if this application for insurance, taken together with any
other insurance policies you already have for this type of insurance, totals to:
• £500,000 or less for life insurance;
• £300,000 or less for critical illness.
Above these limits, you may need to tell us about certain genetic test results when applying for insurance.
We will only be interested in genetic test results where the Government’s Genetics and Insurance Committee
(GAIC) has approved them for insurers to use. If you think this may apply to you, please ask us for details of the
current position. These details are also available from the ABI website at
www.abi.org.uk/Insurance-and-savings/Topics-and-issues/Genetics
However, you must tell us if you either have a family history of, are experiencing symptoms of, or are having
treatment for, a medical condition including any genetically inherited condition. If you wish to disclose to us
a negative genetic test result, which shows us that you have not inherited a genetic disorder, we will take this
into consideration when assessing your application, (providing your clinical geneticist confirms that this test
result indicates a reduced risk of developing the inherited disease).
Medical Information
You must tell us everything that may affect your application. If you have any doubt whether facts are relevant,
please tell us about them. If you do not give us this information, we may not cover you in the event of a claim.
Please note that we reserve the right to request a medical examination within 30 days after the
commencement date of your plan. This forms part of our quality control procedures and individual cases
accepted without medical evidence are selected at random. We may carry out an examination which includes
cotinine testing for tobacco products. In the event that information is not forthcoming or if the examination
highlights a material fact which you have knowingly failed to disclose, we reserve the right to amend the
terms or cancel your plan. You must notify us of any changes which occur before the plan is issued.
Please note, should you die before we receive your signed Customer Signature Form, we will approach your
estate for consent to access your medical records. If consent is not granted then Scottish Widows may not pay
out on your plan.
General Practitioner’s Report Declaration and Consent Important Notes
We may ask you to contact your doctor if we are waiting for reports which we have asked for. If we ask you to
come for a medical examination, we will need to share the application information with another company we
have authorised. They will make the arrangements for the examination to take place.
We may need to send your application and relevant medical reports to our reassurers for their opinion
or agreement of the terms offered. Or, we may need to send them at a later stage for purposes relating to
managing the policy or a claim. You can get details of general reassurance principles and details of any
company we use to assess your application from our head office.
We have a confidentiality policy in place which means we hold your medical information securely and access
is limited to authorised individuals who need to see it.
You are entitled to ask for a copy of our standard terms and conditions (policy provisions) and a copy of your
application form at any time.
The Access to Medical Reports Act 1988, The Access to Personal Files and Medical Reports
(Northern Ireland) Order 1991 and The Access to Health Records and Reports (Isle of Man) Act 1993.
We may need to get medical reports to support your application. Before we can ask any doctor that you have
consulted to fill in a report, we need your permission under the appropriate Act detailed above. Your rights
under the appropriate Act are as follows.
You do not need to give your permission, but if you do not, we may not be able to go ahead with your
application. This does not prevent you from applying to other companies for insurance.
9
IMPORTANT NOTES (CONT’D)
You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to
keep the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the
report within this time, your doctor will send the report to us. If you choose not to see the report at this stage,
you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to
your doctor if you ask to see it at a later date.
If you think that any part of the report is not correct or is misleading, you may ask the doctor to amend it.
If your doctor refuses to make the amendments, you may ask him or her to attach a statement outlining your
views, which will then accompany the report.
Your doctor can withhold access to the report, or any part of it, if he or she feels that it would cause physical or
mental harm to you or others.
The medical report your doctor fills in asks about the following.
• Your current health:
• Any care, medication or treatment you are currently receiving.
• The results of referrals or tests you are waiting for.
• Any time off work in the last three years.
• Your past health:
• Details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions,
• Consultations with your GP or any other medical adviser, therapist or counsellor, in particular whether
you have a history of:
• malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually
worsening) diseases;
• musculoskeletal disease or injury, for example arthritis, rheumatism, back problems or any other
disorder of the joints or muscles;
• Anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder
where you lose contact with reality), stress or fatigue;
• suicidal thoughts or attempts at suicide; or
• conditions related to drug or alcohol misuse or smoking or chewing tobacco products.
• Details of any biopsies, blood tests, electrocardiograms (heart tests), height and weight if measured in
the last two years, urinalyses (tests on urine), x-rays or other investigations.
• Any blood pressure readings in the last three years.
• Any history of disease among your parents or brothers or sisters that you have told your doctor about.
We have asked your doctor not to reveal information about:
• negative tests for HIV, Hepatitis B or C;
• any sexually-transmitted diseases unless there could be long-term effects on your health; or
• predictive genetic test results unless there is a favourable test result which shows that you have not
inherited a condition your family suffers from.
The information you and your doctor provide about your health may result in us:
• refusing to provide insurance;
• increasing premiums above standard rates;
• setting premiums at standard rates; or
• applying additional exclusions.
If you have any questions about your rights under the appropriate Act or questions relating to the process
of getting, assessing or storing medical information, please write to:
Principal Medical Officer, Scottish Widows Limited, 15 Dalkeith Road, Edinburgh EH16 5BU
Do you require to see any medical report on yourself before it is sent to Scottish Widows?
10
Yes
No
H. NOMINATION FORM
Nomination To: Scottish Widows
PLEASE USE BLOCK CAPITALS
Name
Pension Plan Number
(for new policies the Scheme Administrator will insert this when allocated)
I wish to nominate the person/people listed below to receive any death benefits which become payable under
the Pension Plan Number above. I understand that in exercising discretion in applying the benefits the Scheme
Administrator will not be bound by this expression of my wishes.
Please consider the following people to receive death benefits in the percentages shown.
Full name
Relationship (if any)
Percentage of benefits
This form supersedes any earlier form completed in respect of this plan number.
If your circumstances change after submitting this form and you would like to change the nominated
beneficiaries please send a new form.
If you would like further information on placing any death benefit under trust, please tick this box and we will
send you a Scottish Widows Pension Trust form.
Note: Scottish Widows Pension Trust form has been drafted primarily for use by personal pension and
stakeholder pension plan holders who are UK resident. We strongly advise that planholders take legal advice
before completing any trust form in respect of their plan, to ensure that their wishes are properly given effect to.
This is particularly relevant where the planholder is not domiciled in the UK.
Your signature
Date (DD MM YYYY)
11
I. DECLARATION – IMPORTANT – PLEASE COMPLETE
SCOTTISH WIDOWS’ APPROPRIATE PERSONAL PENSION SCHEME (the Scheme)
Please ensure that you read the following important statements relating to your policy:
a) I understand that an application has been made on my behalf to join the Scottish Widows Appropriate
Personal Pension Scheme and that a policy has been issued in my name. Scottish Widows will run the
scheme according to the scheme rules, a copy of these rules are available on request.
b) I agree that the information detailed in the application made on my behalf is correct and complete.
c) I confirm that I am habitually resident in the UK.
d) I authorise Scottish Widows to collect the payments I agree to make, including any transfer payments from
other pension arrangements.
Where necessary, I consent to Scottish Widows seeking further information from other
pension arrangements.
e) I agree that if the basic rate of tax changes, Scottish Widows will amend the amount collected, but only to
the extent necessary to maintain the total payment. Total payments by me in any tax year will not exceed
the higher of £3,600, and my relevant UK earnings.
f) I agree to pay contributions which are at least equal to the difference between the contributions my
employer is paying and the minimum total contributions required by the Pensions Act 2008 (as amended).
I understand that my employer has agreed to ensure that the total of my employer’s contributions and my
contributions is high enough to cover the minimum total contributions required by legislation.
If Scottish Widows realise that the total contributions are not high enough I understand that Scottish
Widows will report my employer to the Pensions Regulator who may issue an unpaid contribution notice
to my employer requiring my employer pay additional contributions.
g) I will inform Scottish Widows within 30 days if I am no longer entitled to receive tax relief.
h) I will inform Scottish Widows if I stop residing in the United Kingdom.
i) I authorise my employer to appoint and/or change the financial adviser for the policy.
j) I agree that my employer, its agents, any agent of mine acting in connection with the plan, and Scottish
Widows may exchange such information concerning me as is necessary to effect and administer the plan.
k) I have received the ‘Important Notes for Applications’ document and the Key Features Document.
Please read these documents. If you do not understand any point, please let us know.
Your signature
Date (DD MM YYYY)
A copy of the completed application, Scheme Rules and Policy Provision is available from Scottish Widows.
12
J. DECLARATION BY EMPLOYER
Declaration by Employer
I/We agree, subject to acceptance of the Employee’s Application for membership of the Scottish Widows
Appropriate Personal Pension Scheme and for the policy or policies to secure benefits thereunder, to pay
either the payments (including any automatic increases to regular payments) shown in Sections E & F of the
application or, if applicable, the payments (including any automatic increases to regular payments) shown in
the Employer’s application.
Your signature
Date (DD MM YYYY)
Position of Signatory
For and on behalf of the Employer
A copy of the completed application, Scheme Rules and Policy Provisions is available from Scottish Widows.
K. DECLARATION OF CONTINUED GOOD HEALTH – ONLY COMPLETE THIS SECTION IF YOU HAVE
COMPLETED SECTIONS F AND G
In connection with the application on my life dated Date (DD MM YYYY)
I
the life to be assured, hereby declare that since that date, and to the
best of my knowledge and belief,
*1. I have continued in good health and have not had any illness or injury, or sought or received professional
advice regarding my health.
*2. There has been no change in family history, occupation, prospects of foreign residence, or prospects of
engaging in any form of flying or hazardous sport or pursuit.
*3. Any subsequent application/proposal on my life made to another office has been dealt with by acceptance
at the ordinary rate of premium.
* Should any of these statements require modification, the clause in question should be deleted, and full
particulars given below.
Signature of the life to be assured
Date (DD MM YYYY)
NOTE: This declaration is valid for 6 weeks from the date of signature shown above.
A further declaration will be required if the first premium or a valid Direct Debit Instruction or Standing Order
is not received by Scottish Widows within that period.
13
DIRECT DEBIT INSTRUCTION
To the Manager
Bank/Building Society
Address
Originator’s ID Number
9
0
6
5
7
2
Postcode
Please complete parts 1 to 4 and 6 to instruct your bank/building society to make payments directly from your account.
When completed please return the form to: Scottish Widows Limited, 15 Dalkeith Road, Edinburgh EH16 5BU.
1. Please write the full postal address of your branch in the box above
2. Name of account holder(s)
3. Account Number
4. Sort Code
5. Payment arrangement reference
For Scottish Widows’ use only.
6. Your instructions to the bank/building society and signature. Please pay Scottish Widows Limited Direct Debits from
the account details on this Instruction, subject to the safeguards assured by the Direct Debit Guarantee.
Signature(s)
Date (DD MM YYYY)
Please note that some banks/building societies may refuse to accept instructions to pay direct debts from some types of account.
Please detach this guarantee and keep it for your records.
THE DIRECT DEBIT GUARANTEE
• This Guarantee is offered 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 Scottish Widows Limited will notify you 14 working
days in advance of your account being debited or as otherwise agreed. If you request Scottish Widows 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 Scottish Widows 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 Scottish Widows 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.
Scottish Widows Limited. Registered in England and Wales No. 3196171. Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN.
Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number 181655.
15800 04/17