Fund Switch – Request Form Single Premium - Aviva

Fund Switch – Request FormSingle PremiumPlease complete sections 1 & 2 and sign below:Section 1Policy NumberPolicy Owner (1)Policy Owner (2)I/We wish to switch units attaching to the above policy(ies) from the existing fund(s) to the new fund(s) of my/our choice asindicated below.I/We understand that the switch will be made on a Bid Price to Bid Price basis, at the bid price declared at the close ofbusiness on the date of receipt of this request by Aviva Life & Pensions Ireland Limited, subject to conditions outlined inthe policy document. Please note that this does not apply to the Secure Capital Fund and/or funds that are currently subjectto a deferral period. Please note that your switch request may be subject to a fund switch charge. Please contact Aviva formore information on this.I/We understand that in the event of an incomplete or invalid fund selection, or where I/We have not submitted the requiredauthorised signature(s), then a new request form will be required subject to the conditions stated in paragraph two above.Section 2Existing Fund Name% New Fund Name%Policy Owner1 SignaturePolicy Owner 2SignatureDate/ /Please Return toLife Policy Servicing DepartmentOne Park Place, Hatch Street, Dublin 2

Aviva Life & Pensions Ireland Limited. A private company limited by shares.Registered in Ireland No. 252737 Registered Office One Park Place, Hatch Street, Dublin 2.Member of the Irish Insurance Federation. Aviva Life & Pensions Ireland Limited is regulated by the Central Bank of Ireland.Life & Pensions One Park Place, Hatch Street, Dublin 2. Phone (01) 898 7000 Fax (01) 898 7329www.aviva.ieTelephone calls may be recorded for quality assurance purposes.5.18.01.13