new member application form - pruadviser · form, please read the notes which are there ... bn2 d d...

Please use black inkand write in CAPITALLETTERS or tick as appropriate.Any corrections must be initialled. Please do not usecorrection fluid as this will invalidate yourapplication. If youneed more space togive details on any ofthe questions, pleasecontinue on a separatesheet, cross-referringto the section.As you complete theform, please read thenotes which are thereto help you.

Page 1 of 20Premier Group Personal Pension new member Application form: P846 05/2018

About this form

New Member application form

Thank you for choosing to join your employers Prudential Group Personal Pension Scheme.

This form can be used to join a Group Personal Pension. Please make sure you have the correct form.

Important note

> Please read the Key Features Document as this will provide you with important information in relation tothe key risks and benefits of your plan. Please also read the Guide to Fund Options that will provide youwith details of the funds, risks and the charges before you make any decisions.

> Some of the information in this form is needed because of HM Revenue & Customs rules so must be correctly and fully completed.

If Other, please state title.

Section A Your details

Full forenamesSurname

Sex Male Female

Date of birth

D D M M Y Y Y Y

Permanent residential address (include postcode)

Postcode

Title Mr Mrs Miss Ms OtherDr

Premier Group Personal Pension

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Premier Group Personal Pension new member Application form: P846 05/2018Page 2 of 20

Section A Your details continued

Are you a Prudential policyholder?

Daytime telephone number Selected Retirement Age*

Yes No

Have you previously accessed benefits flexibly? Yes No

If Yes, please specify the date these were accessed

Yearly earnings

Please includearea code.

*The DefaultRetirement Age for the Scheme willapply unless you tell us that you wanta different age toapply. The minimumretirement age is 55.

Your earnings willallow us to give youmore meaningfulquotations. We willcompare estimatedeventual benefits with your estimatedretirement earnings. If you don't give anearnings figure wewill use the currentaverage weeklyearnings figureprojected to yourretirement date forthe comparison.

National Insurance number

Section B Your employment

Please describe yourduties fully. Includethe industry you workin and provide apercentage splitbetween manual andnon manual duties.If you work atheights, please give details of themaximum height to which you work.

There are a numberof possible ways youmay trigger theMoney PurchaseAnnual Allowance(MPAA) whenaccessing yourbenefits flexibly. Forfurther informationplease speak to yourFinancial Adviser.

What is your occupation?

Name of Scheme

Scheme no. (if known)

Group Personal Pension

R

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D D M M Y Y Y Y

of 20Premier Group Personal Pension new member Application form: P846 05/2018

Section C Eligibility details all applicants

Please tick the box below which best describes your current employment status(or the status of the person for whom this application is being made).

> Employed chargeable to tax under Schedule E (P.A.Y.E.)

> Pensioner chargeable to tax under Schedule E (P.A.Y.E.)

> Self-employed chargeable to tax under Schedule D in respect of self-employment in a trade,profession or vocation or in a partnership.

> Caring for one or more children under age 16

> Caring for a person over age 16

> Full-time education (over age 16)

> Unemployed

> Other

Are you a UK resident for tax purposes?

If No, are you a Crown Servant or married to or a civil partner of a Crown Servant?

If you have answered No to both of the above questions you may not be eligible to makecontributions and get tax relief. You should check this with your scheme adviser.

Yes No

Yes No

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Section D Contributions

Check this with theperson who gave you this form. If thescheme is not splitinto sections pleaseleave blank.

Please tick a box.

What is your Section Number for membership of the scheme?

(a) Regular Contributions

Scale contributions may have already been agreed as part of the Scheme Terms.

Do you want your contributions based on:

1. Scheme TermsPlease go to part (b) below if contributions are a percentageof earnings. Otherwise go to part (c) then (d).

2. Scheme Terms plusadditional contributions

Please go to part (a) below.

3. Individual choice Please go to part (a) below.You should not tickthis box unless youremployer has alreadyagreed to this.

Your regularcontributions and any employercontributions mustboth be a percentageor both be a fixedamount.

Members whojoined before 6 April 2001: thecontribution shownwill include anyWaiver Benefit costs paid by youremployer in terms of this application.

New members who joined after 5 April 2001: thecontribution shown isfor retirement fundingpaid for by youremployer. AnyWaiver Benefit isextra and HMRevenue & Customsrules do not allow taxrelief on the WaiverBenefit cost.

Please show the total contributions amounts before any tax relief

Please show amounts before any tax relief

Please go to part (b) below, if contributions are a percentage of earnings. Otherwise go topart (c) then (d).

% Payable by You: or per month

% Your employer: or per month

(b) Scheme Earnings (if contributions are a percentage of Scheme Earnings)

Please show your Scheme Earnings

(d) Start Date

When do you want to start regular contributions?

(c) Single Contributions

Payable by You:

Your employer:

D D M M Y Y Y YPlease check this withyour employer.

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Section E Investment of contributions

Do you want the Scheme Investment Strategy to apply?

If Yes, please now complete section F.

If No, please discuss this with the Scheme Financial Adviser and complete the remainder of this section.

If you dont want the Scheme Investment Strategy, but want the Lifetime Investment Option or Profile (see below), you can choose the investment linked fund(s) to be used initially, or you can leave the selection to us.

If you do NOT want the Scheme Investment Strategy or the Lifetime Investment Option or Profile, pleasecomplete the table below to confirm the investment fund(s) to be used. If you want the Pension ProtectorOption (see below), you must choose the investment fund(s) to be used.

Lifetime Investment Options/Pension Protector Option/Lifetime Investment Profiles

Lifetime Investment Option Cautious

Lifetime Investment Option Balanced

Lifetime Investment Option Opportunity

Pension Protector Option

If you want to choose the initial funds under the Lifetime Investment Options or Profiles, please complete thetable above. If you do not choose any of the above Lifetime Investment Strategies, we will assume that youare happy to start with the funds we choose for you.

% to be invested in each fund

Chosen FundsRegular

contributionsSingle

contributions

% %

% %

% %

% %

% %

% %

TOTAL 100% 100%

Your employer mayhave set up a defaultfund arrangementcalled a SchemeInvestment Strategywhere yourcontributions will beinvested if you dontmake your owninvestment choice. Thisdoes not represent arecommendation onbehalf of Prudential. Tofind out whether youremployer has chosen aScheme InvestmentStrategy, please speakto the scheme adviser.

If your scheme is beingused for qualifyingpurposes under theBetter WorkplacePensions initiative,your employer musthave a SchemeInvestment Strategy inplace and the chargesfor this strategy cannotexceed an equivalentof 0.75% per year onthe value of fundsunder management,excluding transactioncosts.

Please show thepercentage investmentsplit you want for yourplan if you do not wantthe Scheme InvestmentStrategy.

Please make sure yourtotal equals 100%.

Fractions of 1% shouldnot be used.

The With-Profits Fundis not available for newor additionalinvestment if you arewithin three years ofyour SelectedRetirement Date (and,if chosen, would betreated as anapplication to invest inthe Cash fund).

Please tick only one box.

These options do notapply to With-Profitsinvestments.

Yes No

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If you do not complete this section we will invest your contributions in any Scheme InvestmentStrategy set up by your employer.

Please refer to the Guide to Fund Options for more information on the funds, the associated risksand the charges.

Lifetime Investment Profiletargeting retirement options

Lifetime Investment Profiletargeting cash

Lifetime Investment Profiletargeting an annuity

Lifetime Investment Profiletargeting drawdown


Section F Death benefit beneficiaries

The discretionarydistribution of deathbenefits means thatInheritance Tax willnot normally apply.

If you want to choose additionalbeneficiaries, pleasewrite the details on a separate sheet ofpaper, and attach it to this form.

Failure to complete this part may delay payment of death benefits.

Please show details of the person you would want to get death benefits from your plan.

Prudential has discretion on the beneficiaries for death benefits. In exercising this discretion, Prudential is notlegally obliged to follow your wishes, but will take them into account.

Full forenames

Relationship to you (if any)

%Proportion of benefits

Address

Please make sure thatthe total for all yourchosen beneficiaries is 100%.

Surname

Mr DrMrs Miss MsTitle Other

(If not 100%, details of any additional beneficiariesshould be attached to this application.)

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Postcode


Section G Waiver Benefit

If you are joining the Prudential (SAL)/Prudential (M&G) Scheme for the first time on or after17 January 2005, you cannot apply for Waiver Benefit. If you first joined the Prudential (SAL)/Prudential (M&G) Scheme after 5 April 2001, Waiver Benefit cannot be added after the start dateof the plan.

If your Selected Retirement Age is 60 or below, cover for Waiver Benefit will stop on yourSelected Retirement Age.

If your Selected Retirement Age is above 60, do you want Waiver Benefit to stop:

* If you are applying for Scheme Waiver Strategy, please ignore the rest of this section and now go straight to section H.

# If you do not want to apply for any Waiver Benefit, please ignore the rest of this section and go straight to the Declaration section K.

Regular contributions:

I want to apply for Scheme Waiver Strategy*

I want to apply for Waiver Benefit

I do not want to apply for any Waiver Benefit#

These options are notavailable if you are overage 60 (except forearnings relatedincreases if waiverapplied to your planbefore age 60).These options areavailable if your singlecontributions are part ofa series of singlecontributions to aScottish Amicablepersonal pension planstarted before 6 April2001, but not if you arestarting a series of singlecontributions after age 60.If you already had a Scottish Amicable/M&G personal pensionplan before 6 April2001, any WaiverBenefit in respect ofcontributions added to the plan will be met from the totalcontribution forretirement funding.Also, if you choosewaiver benefit and youremployer is using yourplan for qualificationpurposes under theBetter WorkplacePensions initiative, thereis currently a charge capequivalent to 0.75% peryear on the value offunds undermanagement (excludingtransaction costs) foryour SchemeInvestment Strategy. Ifthis is the case your totalcharges may exceed thecharge cap mentionedabove.However, if you startedyour personal pensionplan on or after 6 April2001 any Waiver Benefitcost does NOT qualifyfor pensions income taxrelief (RAS) AND ispayable in addition topension plancontributions.There must be at leastfive years betweenacceptance for WaiverBenefit for new regularcontributions and theage when you want thebenefit cover to stop.This waiver cessationage cannot be changedlater.The deferred period is the period beforecontributions start to becredited to your plan.The deferred periodcannot be changed.

Please tick only one option.

Single contributions:

I want to apply for Scheme Waiver Strategy*

I want to apply for Waiver Benefit

I do not want to apply for any Waiver Benefit#

Please tick only one option.

Please tick one box

at age 60

OR at your Selected Retirement AgeIf your Selected Retirement Age is over 65,Waiver Benefit will stop at 65 if you tick this box.

How long do you want the deferred period to be? 3 months 6 months 12 months

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Please proceed to section H


Section H Health details complete if you are applying for Waiver Benefit

Name of your doctor

Please proceed to section K if you are not applyingfor waiver benefit, please follow the instructions insections H, I & J if you are applying for waiver benefit.

Important note

> Please take reasonable care to answer thequestions honestly and to the best of yourknowledge. If you don't a claim may be rejectedor not fully paid or your policy may be cancelled.Please answer all questions as failure to do somay mean that your application will be delayed aswe will have to contact you for the missinganswers. Please do not assume we will contactor obtain a report from your doctor.

If someone else fills this form in for you (forexample, your Financial Adviser), please checkthat all the details are correct before you sign the

declaration. You are responsible for all theanswers you or your Financial Adviser provide onthis application. If you make a mistake pleasecross it out, put in the correct word or words andinitial next to the correction.

If you would prefer you may complete themedical questions in private and return theHealth Details section direct to our Chief Medical Officer. Please indicate on this form ifyou have done so.

It is very important that you tell us if there is achange between completion of this form andyour pension starting to any of the informationgiven in sections H, I & J or if you change your occupation.

Your doctors address

Postcode

How long has he/she been your doctor?Your doctors telephone number

years

Have you ever been declined (refused cover), deferred or offered non-standardterms for Life Cover, critical illness or any incapacity benefit?

Yes No

If Yes, please give names of insurance companies and type of policy

Failure to answerthe questionshonestly and withreasonable caremay result in yourclaim being rejectedor not paid in full.

Please do notassume that we will contact orobtain a report from your Doctor.

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Genetic testing

> If this application, taken together with any otherinsurance policies you already have, is for lifeinsurance up to a sum of 500,000 you need notdisclose any genetic test you may have had.

> You need not disclose the result of any genetictest undertaken in the context of research.

> Genetic test results need only be disclosed where the sum exceeds 500,000 for lifeinsurance and their use by insurers has beenindependently approved.

> You may, of course, disclose any genetic testresult which is in your favour.

> If you either have a family history of, are receivingtreatment or experiencing symptoms of a geneticcondition, you must tell us.

> If you wish to disclose to us a negative genetictest result, which shows that you have notinherited a genetic disorder, we will take this intoaccount in setting your premium, providing yourclinical geneticist confirms that the test resultindicates a reduced risk of developing theinherited disease.

> Further information is available on request whichfully explains this policy and details those genetictests approved for use by insurers.


Part Sub heading

Yes No

If you answered yes to any part of Q5 then please give full details.

Have you in the last 5 years, or do you intend to:

i) participate in any sport or pastime which involves any additional risk of accident, such as mountaineering, motor sports, hang-gliding, orunderwater activity?

Yes Noii) live abroad apart from holiday visits?

Yes Noiii) fly, except as a fare-paying passenger on an established public service?

Please now proceed to section I.

Section I Simplified acceptance for Waiver Benefit

The Simplified Acceptance Scheme is designed to minimise the information needed to qualify for WaiverBenefit for those who meet certain criteria.

Please complete this section only if you applied for Waiver Benefit in section G and

> you are under age 50 AND

> the total contribution will be 3,600 gross (including tax relief), or less.

If you are age 50 or over, or your contribution will be over 3,600, please go to section J.

For this purpose,contribution is theyearly equivalent ofcurrent contributionsto the Prudential (SAL)Stakeholder andPersonal PensionSchemes on yourbehalf (regular andsingle contributions)already qualifying for Waiver Benefitunder the SimplifiedAcceptance Schemeplus the contributionsapplied for in this form.

Colds, influenza androutine pregnancyconsultations may be ignored.

1. Have you attended, or been advised to attend, any hospital or clinic for any form of advice, operation, treatment or tests within the last 12 months,OR are you subject to regular medical review or receiving any form of medicaltreatment or attention? Yes No

2. During the last three years, have you suffered from any anxiety, depression or any psychiatric disorder or any disease/disorder of the back OR, have youever suffered from any illness or injury which prevented you from working fora period of two weeks or more? Yes No

If you answered No to both questions, and are under age 50 with contributions of 3,600 gross(including tax relief) or less, please go to section K.

If you answered Yes to either question, please go to section J.

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Section H Health details complete if you are applying for Waiver Benefit continued

Failure to answerthe questionshonestly and withreasonable caremay result in yourclaim being rejectedor not paid in full.

Please do notassume that we will contact orobtain a report from your Doctor.


Section J Your health

Please complete this section only if you have applied for Waiver Benefit and the earlier notes tell you that you should also complete this section OR you want to have Waiver Benefit greaterthan any automatic cover provisions for the Scheme.

1. If we require a Medical Examination to complete our underwriting, pleaseindicate if you want to attend one of our selected examiners or your own GP.

Selected examiner

Own GP

Weight2. What is your height and weight? Height

3. Have you smoked or used any tobacco products in the last 12 months?(includes cigars, cigarettes, pipes and any nicotine replacement therapy etc)

Yes No

Yes No

4. If you have smoked cigarettes, how many do you smoke per day?

Please tick only one box.

Failure to disclose relevantinformation mayresult in nonpayment of a claim. Please donot assume that we will contact orobtain a reportfrom your Doctor.

6. Are you suffering from any symptoms of illness or are you taking pills, drugsor medicine or have you any physical defect or infirmity?

Dates and details

Yes No

Dates and details

7. In the past five years have you

(i) consulted any doctor?

(ii) been prescribed any pills, drugs or medicine?

(iii) been off work for two weeks or more due to illness or injury?

5. What is your average weekly consumption of alcohol in units? (1 unit = 1 single pub measure spirits/small (125ml) glass of wine or 12 pint standard strength beer, lager or cider)


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Failure to disclose relevantinformation mayresult in nonpayment of a claim. Please donot assume that we will contact orobtain a reportfrom your Doctor.

Yes No

8. Have you in the last 5 years consulted a doctor or any other medicalprofessional, or had, or been advised to have, any operation, x-ray, check-upor any other investigation or test or are you intending to do so?

Dates and details

Yes No

Yes No

Yes No

9. (i) Have you ever tested positive for HIV, Hepatitis B or C, or are youawaiting the results of such a test? Note: If the result is negative, the factof having an HIV test will not, in itself, have any effect on your acceptanceterms for insurance?

(ii) Within the last five years have you been exposed to the risk of HIVinfection? (This can be caught through unsafe sex, intravenous drugabuse, or blood transfusions or surgery undertaken outside the EU)

(iii)Within the last five years have you tested positive or been treated for any disease, which was transmitted sexually?

Relationship

Illness (if cancer, whichpart of the body wasaffected?)

Age at onset

Date of death (if applicable)

Section J Your health continued

If yes, please give full details, including nature and date of test, reason for exposure, country involved (if applicable) and/or nature of sexually transmitted disease.

10.Has your father, mother, or any brothers or sisters suffered or died, prior to the ageof 65, from any heart disease or disorder, high blood pressure, stroke, diabetes,cancer, kidney disease, multiple sclerosis, haemochromatosis, motor neuronedisease, Huntingtons disease, muscular dystrophy or any other hereditary disease or disorder?

If yes, please complete this table:

Yes No

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Please read thissection carefullybefore you sign and date this form.

1. New members only: I apply for membership tothe Prudential (SAL)/Prudential (M&G) PersonalPension Schemes. I agree to be bound by itsRules. Please treat this form as severalApplications under the Scheme.

All members: I agree that the SchemeAdministrator should decide on the number of Arrangements.

2. I declare that

> I have taken reasonable care to answer thequestions honestly and to the best of myknowledge. I understand a claim may not bepaid in full or may be rejected or my policymay be cancelled if I have not.

> my total contributions to all UK registeredpension schemes (schemes that attract taxrelief) are subject to HM Revenue & Customslimits and cannot exceed the higher of:

(i) my Relevant Earnings (broadly UK taxable earnings directly from a trade, or profession or employment) and

(ii) 3,600 gross (including tax relief), if myRelevant Earnings do not exceed 3,600.

> if I cease to be a UK resident, for tax purposesor cease to be eligible for tax relief on anycontributions that I am paying (because my earnings have reduced), I will write toPrudential to confirm this before the later of

(i) 30 days after the change, and

(ii) the 5 April at the end of the tax year whenmy circumstances change.

3. I understand that

> my regular contributions, if any (net of tax at the basic rate) will be deducted from myearnings after all other deductions and will besent to Prudential along with my employers/firms contributions (if any) and I authorisesuch deductions from my earnings.

> if my employer is contributing to the plan, my employer intends to continue tocontribute but may stop at any time and,if this happens, I will be told.

> I can alter the terms of my plan by givingrevised instructions to Prudential, in writing,and that these revisions can be either directlyfrom me, from my employer, or from thefinancial adviser who arranged my plan (or from any other adviser agreed by myemployer as the adviser dealing with theGroup Personal Pension Scheme andconfirmed in writing to Prudential) providedthat Prudential agree the proposed change(s)and that they are allowed in terms of the Rules.

> Prudential may alter the terms of my plan if I apply to continue the plan having left the Group Personal Pension Scheme.

> tax rules may change in the future and areliable to change without notice. The impact of taxation (and any tax reliefs) depends onindividual circumstances.

I understand that if I am a member:

> Who joined the Prudential (SAL)/Prudential(M&G) Personal Pension Scheme for the firsttime prior to 6 April 2001, and

My employer is using my scheme forqualifying purposes, and

I have chosen waiver of premium, my chargesmay exceed the charge cap of 0.75% per yearon the value of funds under management,excluding transaction costs.

4. I consent to

> Prudential giving my employer/firminformation about my plan.

> Prudential getting more information, andI consent to the giving of such information,as may be necessary for the installation andadministration of my plan.

> Prudential providing the Financial Adviserdetailed in this Application Form, informationon all my Prudential Individual Pension Plans(including group arrangements). This authorityis valid until it is cancelled, in writing, by me,or by submission of future applications.

Section K Declaration

As HM Revenue & Customs grant tax relief at source on the strength of this application, you shouldbe aware that it is a serious offence to make false statements; the penalties are severe and couldlead to prosecution.

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Section K Declaration continued

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How we use your personal information

We, Prudential UK, may receive your personalinformation from the trustees of a pension scheme,your employer, or other financial servicesorganisations (known as a Data Provider) and/ordirect from you. Regardless of where we obtain suchinformation from, we take the privacy and protectionof your personal information seriously. We own thepersonal information we hold about you and decidewhat happens to it. This makes us a Data Controllerin respect of the personal information. You shouldnote that the Data Provider will also be a datacontroller in respect of the personal information theyhold about you.

Weve set out below information about ourprocessing of your personal information, what rightsyou have, and how you can get in touch if you wantto know more.

When we say personal information, we meaninformation about you which we receive from a DataProvider or any other personal information youprovide directly to us. For example, this may includeyour name, date of birth and contact details. Wecollect personal information from you that isnecessary for us to either provide you with theproduct or service youve requested or to complywith statutory or contractual requirements.Unfortunately if you dont provide all of theinformation we require this may mean we are unableto provide our products and services to you.

Part A How we use your personalinformation and why We, the Prudential Group and our Business Partners,will use the personal information for the followingpurposes:

> the administration of our products and services,including to enable us to perform our obligationsunder any contracts or policies to you and toprovide any relevant services as discussed withyou prior to any purchase of a product or service

> complying with any regulatory or other legalrequirements

> carrying out checks using agencies such as creditreference agencies, tracing companies, or publiclyavailable information (See Part B for more)

> the provision of customer services like to reply toa question, or tell you that somethings changing

> automated decision-making or profiling (see PartC for more)

> keeping your information on record and carryingout other internal business administration

In addition, we, the Prudential Group, and ourMarketing Partners, will use the personal informationyou provide to us, together with other information,to send you direct marketing offers by electronic andnon-electronic means including by post, as well assending you introductions to products and servicesfrom carefully selected third parties also by post.Please see Part G for further details.

Some of the purposes above are necessary to allowus to perform our contractual obligations to you andto enable us to comply with applicable laws andregulation. We may also rely on legitimate interestsin using and sharing your personal information forthe purposes described above to improve ourproducts and services. This allows us to exploreways to develop our business and to gain insightsinto how our products and services are used. To theextent that we need your consent to use yourpersonal information for the purposes describedabove, you explicitly provide your consent by signingand returning this form, or as set out in Part G asappropriate. To the extent that your personalinformation is provided to us by a Data Provider andwe need your consent to use your personalinformation for the purposes described above, theData Provider is responsible for providing theconsent to us.

Who we share your personal information withand why

Well share your personal information within thePrudential Group and with our Business Partners, forany of the purposes set out in Part A. If you have ajoint policy or investment, the other person mayreceive your personal information too. If appropriate,we may also pass on your personal information tofinancial crime prevention agencies, any legal,regulatory or government bodies.

As we, the Prudential Group, and some of ourBusiness Partners are global companies, we mightneed to send your personal information to countriesthat have different data protection laws to the UK orthe European Economic Area. These transfers willonly be to countries in respect of which theEuropean Commission has issued a data protectionadequacy decision, or to other countries, such asIndia or the United States of America, whereappropriate safeguards have been put in place.

If you want to know more about these safeguards like our use of the European Commissions ModelClauses which govern the transfer of informationoutside of the European Economic Area furtherinformation is available on request.

Any transfer of your personal information will alwaysbe done securely.



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We keep your personal information for a setamount of time

Your personal information will be stored either for aslong as you (or your joint policyholder) are ourcustomer, or longer if required by law or as isotherwise necessary. Itll always be in line with ourdata retention policy.

Part B Reference checksFor certain products, we may use approved creditreference agencies, tracing companies, financialcrime prevention agencies, or publicly availableinformation, to help us to check your identity, as wellas to prevent fraud and money laundering; this mayinclude checks on your current or previousaddresses. Results of these may be recorded forfuture reference.

These checks may also be carried out for a jointpolicy holder or person(s) that you provide personalinformation on. Should we ever lose contact withyou, we may use these agencies to verify youraddress to help us get back in touch.

Part C We may use your personalinformation to make automated decisionsor profile youWe, the Prudential Group, our Business Partners,and our Marketing Partners may use your personalinformation to make automated decisions affectingyou or to conduct other profiling (for example,marketing profiling).

To the extent that we conduct such automateddecision making activity, well provide you withfurther information at the appropriate time.

Part D Use of your sensitive personalinformationFor certain products or services, well need toprocess your sensitive personal information, such asinformation relating to health, genetics, biometricidentifiers and sexual orientation, a Data Providermay from time to time provide this to us. In suchcircumstances the Data Provider is responsible forobtaining any explicit consent necessary for us toprocess this kind of personal information.Alternatively, if you provide sensitive personalinformation to us, to the extent that we need yourexplicit consent to process this kind of personalinformation in the manner described in Parts A, B,and C, you explicitly provide your consent by signingand returning this form.

Part E Youre in control When it comes to how we use your personalinformation, youve got the right to:

> request a copy of your personal information forfree (we may charge you for this if the request ismanifestly unfounded or excessive)

> in certain circumstances request that we moveyour personal information to another organisationif you want us to

> request that we correct anything thats wrong, orcomplete any incomplete personal information

> ask us to delete your personal information if it is nolonger needed for the purposes set out in Part A orif there is no other legal basis for the processing

> limit how we use your personal information orwithdraw your consents (including automateddecision making) you have given for theprocessing of your personal information

> object to us using your personal information fordirect marketing (including related profiling) orother processing based on legitimate interests

> complain to a data protection authority or anotherindependent regulator about how were using it.

If you want to do any of these things, or would likean explanation as regards these rights, weveexplained how you can get in touch in the ContactUs section.

If you do need to speak to us, itll be useful to haveto hand that the data controller of your personalinformation is Prudential UK. Prudential UK have alsoappointed a Data Protection Officer who can bereached at the address shown in the Contact Ussection of this document.

We may monitor or record calls or any othercommunication we have with you. This might be fortraining, for security, or to help us check for quality.

As set out at the start of this notice, a Data Provideris also a Data Controller in respect of your personalinformation and you are likely to have similar rights in respect of the personal information held by a Data Provider.



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Part F Acting on someone elses behalf?If you give us personal information about anotherperson (or persons), well take that to mean theyhave appointed and authorised you to act on theirbehalf. This includes providing consent to:

> our processing of their personal information andsensitive personal information (as weveexplained in Parts A, B, C, and D above)

> you getting any information protection notices ontheir behalf.

If for any reason you are concerned as to whetheryou are permitted to provide us with the otherpersons information, please contact us on the phonenumber below before sending us anything.

Part G Direct marketingWe and the Prudential Group will still send youinformation by post about the Prudential UK and thePrudential Groups products and services andcarefully selected third parties.

Additionally, from time to time, Prudential UK andthe Prudential Group would like to contact you byelectronic means with details about products,services and any special offers. Please note that anyconsent you give will not apply to M&G InvestmentsGroup, Prudential International Assurance plc andPrudential plc as they operate their own customerdatabases and may contact you separately.

If you consent to us contacting you for this purposeby electronic means, please tick to say how we maycontact you (tick as many or as few as you like):

Email Phone Text

And if you change your mind, and/or you would liketo opt-out of receiving non-electronic directmarketing, its easy to let us know. Just call us on0800 000 000.

Contact usIf you want to exercise your rights in Part E or if yourequire any other information about any other part ofthis notice, you can contact us in a number ofdifferent ways.

Write to us at: Customer Service Centre Prudential Lancing BN15 8GB

Call us on: 0800 000 000

Or visit: www.pru.co.uk

Prudential UK means The Prudential AssuranceCompany Limited and Prudential Pensions Limited,as appropriate.

The Prudential Group means any affiliates ofPrudential UK (including, Prudential DistributionLimited, Prudential International Assurance plc,Prudential Plc, Prudential Services Limited, PGDS(UK ONE) Limited, Prudential Life Time MortgagesLimited, Prudential Global Services Private Limited,Prudential Corporation Asia, Jackson National Lifeand PPM America, Inc. M&G Investments Group,Prudential Financial Planning Limited and PrudentialCorporate Pensions Trustee Limited).

Business Partners means our service providers,accountants, auditors, IT service and platformproviders, intermediaries, reinsurers,retrocessionaires, investment managers, agents,pension trustees (and other stakeholders), schemeadvisors, introducers, selected third party financial andinsurance product providers, and our legal advisers.

Marketing Partners means our service providers,intermediaries, pension trustees (and otherstakeholders), scheme advisors, introducers and selected third party financial and insuranceproduct providers.

Important notesThe plan will not start until we have assessed andaccepted your application, and the first premium has been paid. If you have a birthday while yourapplication is being processed, the terms may differfrom those originally quoted.

In most instances your payments will be as originallyquoted. We may offer you revised terms, butoccasionally we may not be able to offer any terms.

We may ask you to contact your doctor if we arewaiting for reports which we have asked for.

If we ask you to come for a medical examination, wewill need to share the application information withanother company we have authorised. They willmake the arrangements for the examination to take place.

We may need to send your application and relevantmedical 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 purposesrelating to managing the policy. You can get details of general reassurance principles and details of anycompany we use to assess your application, from our head office.

We have a confidentiality policy in place whichmeans we hold your medical information securelyand access is limited to authorised individuals whoneed to see it.

You are entitled to ask for a copy of our standardterms and conditions and a copy of your applicationform at any time.



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Access to medical reportsYour Statutory Rights Under The Access toMedical Reports Act, 1988 and The Access To Personal Files and Medical Reports (NI)Order 1991

We may need to get medical reports to support your application. Before we can ask any doctor thatyou have consulted to fill in a report, we need yourpermission under the Access to Medical Reports Act,1988. Your rights under the Act, are as follows.

You do not need to give your permission, but if youdo not, we may not be able to go ahead with yourapplication. This does not prevent you from applyingto other companies for insurance.

You can ask to see the report before the doctorreturns it to us. If this is the case, we will tell thedoctor to keep the report for 21 days so that you canarrange to see it. If you have not made arrangementsto see the report within this time, your doctor willsend the report to us.

If you choose not to see the report at this stage, youmay ask the doctor for a copy within six months of itbeing 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 corrector is misleading, you may ask the doctor to amend it.If your doctor refuses to make the amendments, youmay ask him or her to attach a statement outliningyour views, which will then accompany the report.

Your doctor can withhold access to the report if he or she feels that it would cause physical or mentalharm 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 (excluding minor self limitingailments/conditions) of any relevant illness,trauma, or referrals for specialist advice ortreatment, hospital admissions, consultationswith your GP or any other medical adviser,therapist or counsellor, in particular whetheryou have a history of:

malignancy (cancer), cardiovascular (heart)disease, diabetes, and degenerative(gradually worsening) diseases;

musculo-skeletal disease or injury, for example,arthritis, rheumatism, back problems or anyother disorder of the joints or muscles;

anxiety, depression, neurosis (such asphobias, obsessions and so on), psychosis (a mental disorder where you lose contactwith reality), stress or fatigue;

suicidal thoughts or attempts at suicide; or

conditions related to drug or alcohol misuseor smoking or chewing tobacco.

> details of any biopsies, blood tests,electrocardiograms (heart tests), diagnosticgenetic test results, height, 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 yourdoctor 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.The information you and your doctor provide aboutyour health may result in us:

> refusing to provide insurance;> increasing premiums above standard rates; or> setting premiums at standard rates.> setting exclusions or postponing cover.If you have any questions about your rights underthe act or questions relating to the process ofgetting, assessing or storing medical informationplease write to:

Chief Medical Officer, Prudential, Lancing BN15 8GB

I do not want to see the report before it is sent to the company.

I do want to see the report before it is sentto the company.

of 20Premier Group Personal Pension new member Application form: P846 04/2018Premier Group Personal Pension new member Application form: P846 05/2018

Additional notes

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Signature of applicant

Date

D D M M Y Y Y Y

Declaration

> I understand that this Application is subject to written acceptance by Prudential.

> I agree to you asking any doctor I have consultedabout my physical or mental health to providemedical information so you may assess myproposal. You may gather relevant informationfrom other insurers about any other applicationsfor life, critical illness, sickness, disability,accident or private medical insurance that I haveapplied for. I authorise those asked to providemedical information when they see a copy of thisconsent form. This form allows you to gathermedical reports within six months of the start ofthe plan, or after my death, to support any claimmade on the plan proceeds.

> This information can also be used to maintainmanagement information for business analysis.

Prudential as administrator agrees toadminister the prudential (SAL)/(M&G)personal pension schemes as required by the rules of the scheme.

If this application has been pre-filled for you,you should read all the statements and answerscarefully (to recheck your understanding andthe accuracy) before signing the form.

If I have applied for Waiver Benefit, I haveread the declaration, important notes andinformation relating to my rights under theAccess to Medical Reports Act.

For your own benefit and protection you need to read carefully the documentation providedbefore signing this form. You also need to readcarefully any further documentation provided toyou in the future. If there is anything you do notunderstand please ask us for further information.


For completion by Financial Adviser essential information

For Prudential use only

Cheque Acknowledgement Number Cheque amount

Date stamp

Advice given

PFR

M

Yes SCC

AM

AOI

No

Yes No

CCC

EC

AC

Yes No

Yes No

Yes No

Please complete this section to show the adviser charge details for any single contribution in this application. Please note that if thisscheme is being used for qualifying purposes under the Better Workplace Pensions initiative, we will not pay commission.

Flat percentage NOT LAUTRO

% to be takenTick only one box

a) Initial %

b) Fund related %

d) Nil adviser charge

c) Mixed initial/Fund related

Initial

%

Fund related

%

e.g. 1 2 3 4 5 X

Your Prudential Company Representative Number (if applicable)

Your FCANumber (Registered Individuals)

e.g.

R.I. Number OR

AND

Registered Individuals forename

Registered Individuals surname

A B C 1 2 3 4 5

Was advice given? Yes No

BN18


Additional notes

BN19

P846 05/2018

"Prudential" is a trading name of The Prudential Assurance Company Limited, which is registered in England and Wales. This name is also used by other companies withinthe Prudential Group. Registered office at Laurence Pountney Hill, London EC4R 0HH. Registered number 15454. Authorised by the Prudential Regulation Authority andregulated by the Financial Conduct Authority and Prudential Regulation Authority.

www.pru.co.uk

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