APPLICATION FOR REGISTRATION OF A PENSION PLAN AMENDMENT (All applicable questions must be completed) "*" indicates required fields INFORMATION ABOUT THIS APPLICATION1: Plan registration/reference number* 2: Name of pension plan*3: Name of employer*4: The effective date of the amendment is:* YYYY dash MM dash DD 5: Amendment number(s) (if multiple amendments are submitted):*6: Indicate whether the application involves an amendment(s) concerning:* transfer of assets merger of plans refund of contributions plan name change vesting reduction of accrued benefits or refund of contributions change of trustee change of administrator full wind up of the pension plan partial wind up of the pension plan pensionable earnings other If other, provide details* 7: Indicate whether the application involves any of the following (please answer each question):* eligibility for membership* Yes No normal retirement age* Yes No employee contributions rate* Yes No employer contributions* Yes No benefit calculation/formula for plans providing defined benefits* Yes No benefit calculation/formula: career average earnings* Yes No the provision of automatic (contractual) increases to pensions in pay or deferred pensions* Yes No ad hoc increases to pensions in pay or deferred pensions* Yes No funding instrument* Yes No ADDITIONAL INFORMATION RELATED TO AMENDMENT(S)8 (a): Does this application involve an amendment to provide ad hoc increases to pensions in pay or deferred pensions? (if “yes”, answer (b) and (c) below; if “no”, go to paragraph 9)* Yes No 8 (b): How are these increases to be made?* ad hoc increase pursuant to a collective agreement and plan amendment ad hoc increase made voluntarily by the employer in accordance with a plan amendment Other 8 (c): What was the effective date of the increase?* DD dash MM dash YYYY 9: Funding instrument / arrangement *Are the benefits provided for in the plan totally insured or guaranteed, or both?* Yes No 10: Indicate the type of plan (in cases where this amendment changes the type of plan, indicate the new plan type)* multi-employer defined contribution defined benefit combination of defined benefit and defined contribution financial institution Other defined benefit* defined contribution* 11: Eligibility for membership *Specify the class or classes of employees who are eligible to join the plan:* all employees Bermudians and husbands or wives of Bermudians Other 12: Normal retirement age* Indicate normal retirement age according to plan text13: Employee contributions*Identify employee contribution rate:* no employee contribution required % of pensionable earnings % of pensionable earnings above required contribution rate Other % of pensionable earnings* % of pensionable earnings above required contribution rate* 14: Employer (includes self-employed) contributions *Identify employer contribution rate or amount:* employer pays employee contribution % of pensionable earnings % of pensionable earnings above required contribution rate per year Other % of pensionable earnings* % of pensionable earnings above required contribution rate* per year* Pension Plans Which Have A Defined Benefit Provision, Complete Paragraphs 15 to 1815: Benefit calculation *Are pension benefits per year of service based on (check the most appropriate):* final average earnings over the last x years best average earnings for the best x1 years (of the last x2 years, if applicable) career average earnings flat benefit Final average earnings over the last x years* Best average earnings for best x1 years* (of the last x2 years, if applicable) 16 (a): If the benefit calculation is based on career average earnings, are career earnings or benefits updated, for example, in accordance with a price or wage index?* Yes No 16 (b): If the benefit calculation is updated, are all earnings included or only those after a specified date?* Yes (all earnings included) No (only after specified date below) earnings included after date* DD dash MM dash YYYY 17: Benefit formula - for normal retirement benefit only (do not include optional or alternative benefits requiring specific conditions) *Indicate amount or rate of benefit formula per year of service: *of earnings per month for each year of service per month for each hour(s) worked other (provide details) 18: Does this application involve an amendment to provide for automatic (contractual) increases to pension in pay or deferred pensions (e.g. indexation to Consumer Price Index)?* Yes No Payment InformationApplication Fees: $200* Wire Transfer Credit/Debit Card Credit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Upload Proof of Payment*Max. file size: 20 MB.Please make cheque payable to the: Pension Commission or payments can be made directly to the Commission’s bank account. Please submit this Form with proof of payment uploaded.AmountDECLARATIONI,* hereby apply for registration of the Pension Plan amendment identified in this Form in accordance with the Act and the Regulations. Attached is a certified copy of the amending document as well as any other document required to be submitted under the Act and the Regulations.(Name of the pension plan)* Attach certified copies of the documents that support this application and required to be submitted under the Act and the Regulations. Drop files here or Select files Accepted file types: pdf, jpg, doc, docx, Max. file size: 768 MB. I DECLARE THATComply* The documents submitted with this Form include a certified copy of the amending document(s) and that/ those document(s), as well as all other documents submitted with this application, comply with the provisions of the Act and the Regulations; Obligcation* I understand that the obligation to ensure that the documents submitted with this Form comply with the Act and the Regulations is the responsibility of the administrator, and I declare that I have fulfilled that obligation and have complied with the provisions of the Act and the Regulations in making this application for registration; and Documents* I am aware of the administrator’s obligations under the Act as administrator of the Pension Plan and that the contents of this Form and the documents submitted with this Form, and my declarations are true to the best of my knowledge and belief. DATED* DD dash MM dash YYYY Email* Signature of Witness*Signature of authorized signing officer*Name of Witness (printed)* Name of authorized signing officer (printed) Title/Position
