Please Select Your Financial Adviser – Select –Richard GroverHelen PengellyLuke Harris-JohnsMatthew RannCompany Name:

1) Suitability of the Insured Benefits

A summary of the insured benefits has been included with this questionnaire. a) We are satisfied the policy covers the required persons and the benefits remain suitable for our requirements and we do not wish to consider any changes b) We would like to consider changes to the persons who are covered under this scheme and/or the level of insured benefits provided by the policy

2) Scheme Structure (GLA Only)

Group Life assurance schemes must be placed in a trust. In order to assess the continued suitability of the current trust structure for your scheme, please can you confirm the following:

a) Been diagnosed with a terminal illness Yes NoEnter Employee Name/DOB/Diagnosis Add additional employee? Yes NoEnter Employee Name/DOB/Diagnosis b) Registered for any form of pension protection (Fixed or Enhanced) with HMRC Yes NoEnter Employee Name/DOB/Enhanced or Fixed Add additional employee? Yes NoEnter Employee Name/DOB/Enhanced or Fixed c) total pension benefits above the Pensions Lifetime Allowance (LTA) which is currently £1,073,100 for the 2023/24 tax year? Yes NoEnter Employee Name/DOB/Enhanced or Fixed Add additional employee? Yes NoEnter Employee Name/DOB/Enhanced or Fixed

3. Long Term Absentees & Serious Illness

a) Are you aware of any employee who is not absent from work but is known to suffer from a serious illness that could result in a claim (e.g Cardiac conditions, degenerative neurological conditions, Stroke, Cancer or Terminal Illness diagnosis) Yes NoEnter Employee Name/DOB/Diagnosis Add additional employee? Yes NoEnter Employee Name/DOB/Diagnosis b) We confirm that there are no members to be insured under the scheme(s) who have been absent from work for 1 month or longer as of today’s date. Yes NoEnter Employee Name/Date of 1st absence/Reason for absence Add additional employee? Yes NoEnter Employee Name/Date of 1st absence/Reason for absence

4. Benefit Termination Age

The date the benefits cease for an insured employee is confirmed under ‘Benefit Termination Date on the summary of insured benefits included with this questionnaire

Are there any insured employees who will reach the benefit termination date within the next 12 months, who you would like to continue to cover under the scheme, subject to the Insurers requirements. Yes NoEnter Employee Name/DOB Add additional employee? Yes NoEnter Employee Name/DOB

5. Persons to be insured

Please indicate by ticking the relevant box, all categories of employee you wish to be covered under this scheme Full time permanent employees Part time permanent employees FT or PT Employees on probation Directors (salaries/dividend based) Employees on Fixed Term Contracts Employees on Zero Hour Contracts

6. Membership Data

We require an up to date list of all persons to be covered under the scheme/s.  The details we require are listed below and these should be provided in an excel spreadsheet and returned to us via the Wingate Portal or if by e-mail as a password protected document. A template of the spreadsheet has been attached to the pre renewal e-mail.

Full employee name

Date of birth

Gender

Employment start date

Annual Salary  (reflecting definition of scheme salary on enclosed benefit summary)

Job title

Category of employment (Permanent, Probation, Fixed Term Contract, Zero Hours etc)  

Postcode where employee works

Details of any regular work related overseas travel (destination, duration and frequency)

Identify anyone who undertakes more than 20,000 annual business miles in their vehicle (excludes personal use and commuting to from normal place of business)

Your Full Name Position Date Submit Form