OMI Broker number. (if applicable) OMLAC(SA) code. (if known) (if applicable) Company name. Address. Telephone number. Cell number.

Transcription

1 Financial Adviser s details OMI Broker number Name of financial adviser startin your Old Mutual International Investment Portfolio for the individual investor OMI consultant code (if applicable) OMLAC(SA) code (if known) Corporate adviser code (if applicable) Company name Address Telephone number Cell number address FAIS Licence Number Categories of FAIS Licence held Old Mutual Isle of Man only accepts business introduced by intermediaries which have Terms of Business with us. All introducers must be FAIS licensed. This Application Form should only be used when applying for the Old Mutual International Investment Portfolio, a Capital Redemption Contract issued as long term insurance business under the Isle of Man Insurance Act 2008 by Old Mutual Isle of Man, branch of Old Mutual Life Assurance Company (South Africa) Limited, and should be read in conjunction with: - the Investment Portfolio Product Brochure - the Investment Portfolio Key Features Document - the Investment Portfolio General Conditions You should also refer to the appropriate Key Features addendum for details of Authorised Custodian charges. Discretionary Investment Manager charges are available from your chosen Fund Adviser. This Application Form is for individual Contract Holders only. If you are a trustee or corporate Contract Holder you should use the alternative application form which is available from your financial adviser. When completing this Application Form, please use BLOCK CAPITALS and blue or black ink only and complete all relevant sections. Please do not use correction fluid; any amendments should be crossed out and signed by all Contract Holders. When the singular is used in this application form (for example I/my) then it also includes the plural (for example we/our). Any incomplete information will need to be confirmed in writing by you to Old Mutual Isle of Man. If this investment is to be linked to an existing Investment Portfolio Plan please state the Plan number. February 2012 Page 1 of 28

2 A Details of all individual Contract Holder(s) In this section, please give details of all individual Contract Holder(s). Contract Holders must be at least 18 years old and the maximum age is 89. If there are any further Contract Holders, please photocopy Section A (both pages), attach the details with this application form and tick here (3) (The maximum number of Contract Holders is six.) Contract Holder 1 Contract Holder 2 (if any) Title (3) Mr Mrs Miss Mr Mrs Miss Other Other Full forename(s) Surname Previous name or alias Sex (3) Male Female Male Female Date of birth Country of birth Nationality Dual nationality (if applicable) Passport number/national identity document number Country of residence Residential address (where you currently live. This address must match the address given in the document to verify residential address.) Postcode Postcode Stand/Plot/Erf Number Postal address* (must be completed if different from residential address; plan correspondence will be sent to Contract Holder 1) Telephone number Postcode Postcode Fax number Cell number address Occupation (if you have retired please include your occupation before retirement) Industry / employer Income tax number Reason for investment (for example, saving for retirement) *Old Mutual Isle of Man will normally correspond using the correspondence address, however there may be circumstances where correspondence will be sent to the residential address. Page 2 of 28

3 A Details of all individual Contract Holder(s) (continued) Politically Exposed Persons (PEP) If the Contract Holder(s), or any other party connected to this application either now or in the past/future, could be classed as a PEP, or connected with a PEP, please provide details. A PEP is an individual or entity that is, or has been, entrusted with a prominent public function or such parties associated with them. Contract Holder 1 Contract Holder 2 Please note that we will need further documentary evidence on the origin of wealth to support applications from parties who are, or are connected to, PEPs. ALL CONTRACT HOLDERS MUST COMPLETE AND SIGN THE DECLARATION IN SECTION G. B Contribution and Investment Portfolio currency Currency (3) US$ CHF AU$ Investment Amount - Where no Advice Fee is taken the amount indicated in the Investment Amount will be equal to the Contribution. Where an Advice Fee is taken the Contribution amount will be the Investment Amount minus the Advice Fee as indicated in Section D. We recommend that you keep around 2% of your Contribution in the Transaction Account held with Old Mutual Isle of Man to cover ongoing charges. What proportion of your Contribution would you like allocated to the Transaction Account held with Old Mutual Isle of Man? Please note it is your and/or your Fund Adviser's responsibility to ensure liquid assets are available to pay ongoing charges. % Or enter the Rand amount here and indicate the currency and approximate equivalent amount above Minimum initial investment is 100,000 or 150,000 for other currencies, spread equally across the number of Contracts either chosen by you or across Old Mutual Isle of Man s default number of 100 Contracts if not specified by you. For additional Linked Contracts, the minimum is 50,000 or 75,000 for other currencies. Contract Currency Contract Currency (3) US$ CHF AU$ Please tick ONE Contract Currency ONLY. The Contract Currency cannot be changed once the Contract has been issued. Please note if no currency is entered your Contract Currency will be Pound Sterling ( ). Your regular Plan valuation will be summarised in your chosen Contract Currency. In addition, the total value of your Investment Portfolio will also be valued in South African Rand. If you choose a Contract Currency other than that in which you made your Contribution, you should be aware that we will notionally convert the Contribution into your chosen Contract Currency. This means we will not physically convert the Contribution; but the converted amount will be the amount which is shown in your Plan Summary. Any conversions that we make will be based on the closing 'market mid-rate'* provided to us by a third-party currency rate provider on the Working Day before we allocate your Contribution to your Contract. If additional currency conversions are required as a result of transactions within your Contract, you should be aware that delays may occur. Please refer to the Investment Portfolio General Conditions for any charges which may apply. * All currencies have a market rate. Any provider dealing with currencies will independently set different 'buy' and 'sell' rates, which include overheads and profit margins. The market mid-rate is derived from the mid-point between the 'buy' and 'sell' rates used in the global markets. Page 3 of 28

4 B Contribution and Investment Portfolio currency (continued) Payment method Please select your payment method (3) Electronic bank transfer Asset transfer (please complete the table below) Number of shares/units/nominal asset value Security identifier SEDOL/ ISIN Full name and type of asset Please indicate: certificated, non-certificated or held by agent Account number of non-certificated securities Approximate value All assets to be transferred will be reviewed and must be acceptable to Old Mutual Isle of Man. All stocks and shares must be quoted on a stock exchange recognised by Old Mutual Isle of Man. Please contact Old Mutual Isle of Man regarding other assets which may be acceptable at its discretion. Further information will be supplied including details of valuation procedures which will be adopted in respect of such holdings. Old Mutual Isle of Man will confirm to the Contract Holder(s) when the transfer process can start. It is the responsibility of the Contract Holder(s) to start and monitor the transfer process. You can only use the asset transfer facility if the total value of assets is more than 50,000 (or 75,000 for other currencies) in total and each stock to be transferred has a value greater than 5,000 (or 7,500 for other currencies). Number of Contracts Old Mutual Isle of Man automatically issue 100 Contracts unless otherwise stated. The minimum is one and the maximum is 1,000. If you select too many Contracts for your Contribution, we will default to the maximum number of Contracts allowable.the number of Contracts cannot be changed after the Plan is set up. Please enter the number of Contracts you would like: or tick here for maximum allowable for your Contribution (Minimum per Contract is 500 or 750 for other currencies.) Your Contribution will be held in the Transaction Account held with Old Mutual Isle of Man and then transferred to the Transaction Account with the Authorised Custodian, awaiting investment instructions. Therefore, there may be a delay between our acceptance of your Contract and your Contribution being invested. C Request to open an Authorised Custodian account We strongly recommend you review and complete your own due diligence on the Authorised Custodian before you request us or the Reinsurer to appoint them to ensure they satisfy your requirements. Full details of the Authorised Custodian and services can be found on the Authorised Custodian s own website. Where you request an Authorised Custodian not listed below, this will be subject to our agreement. I request that Old Mutual Isle of Man or the Reinsurer appoints (3) (Please select only one option) Collins Stewart Wealth Management Credo Capital plc Savoy Investment Management OR with the intent that the Authorised Custodian shall hold the Assets of the Portfolio Fund and shall be responsible for their safe custody. For details on each of the Authorised Custodians charges, please refer to the Key Features addendum of the Investment Portfolio Key Features Document. Old Mutual Isle of Man is the provider of the Investment Portfolio and will issue the contract. All the assets held in the Investment Portfolio will legally be owned by Old Mutual Isle of Man, however, Old Mutual Isle of Man is entitled to reinsure our obligations under the Investment Portfolio to an appropriate Reinsurer, in which case the Assets will legally be held by the Reinsurer. The fact that we may allow or refuse a particular Authorised Custodian does not indicate any judgement by us about its financial stability, services or suitability for you. Please see Section G 'Authorised Custodian' for more information on opening an Authorised Custodian account. Page 4 of 28

5 D Charges The charging structure and currency that you choose for your Investment Portfolio cannot be changed once the Investment Portfolio has started. Charges and Fees payable to your financial adviser Please see terms 18 to 21 of the General Conditions for detailed information on charges or speak to your financial adviser. Please also see Section G of this Application Form, 'Commission, charges and fees' for a full explanation of the commission and fees to be paid to your financial adviser. VAT will be included in commission payments where applicable. Please indicate your chosen charging structure and complete the relevant information (3) (If no box is ticked, the application cannot be processed) Charging option 1 Commission to be paid % Commission being waived % (Should total 3%. VAT will be added if applicable) Any commission being waived should be used to reduce the Contract Establishment Charge or % commission to be paid upfront and the balance to be paid in equal amounts enhance the Allocation Percentage quarterly in arrears over the next 1 year half-yearly 2 years subject to a maximum equivalent to 1% per annum. VAT will be added if applicable. yearly 3 years Where the financial adviser is acting as the Fund Adviser (Discretionary Investment Manager), any fees in respect of this role should be entered in Section F. The Investment Review Fee is a fee agreed between you and your financial adviser. Any payment will be taken as a partial surrender. For clarity, this is not a commission payment. 4 years 5 years Investment Review Fee starting on of % per annum of the value of my Portfolio Fund to be taken quarterly half-yearly subject to a maximum equivalent to 1% per annum or 1.14% if VAT is applicable, and minimum payment of 500, payable once any commission has ceased. yearly Charging option 2 Advice fee of % The Advice fee is an amount agreed between you and your financial adviser. This amount will be deducted from the amount you have indicated in Section B. For clarity, the advice fee is not a commission payment. In addition, total commission of (Maximum of 3% or 3.42% if VAT is applicable) % to be paid in equal amounts quarterly in arrears over the next 1 year (Maximum of 3%. VAT will be added if applicable) half-yearly 2 years subject to a maximum equivalent to 1% per annum. VAT will be added if applicable. yearly 3 years Where the financial adviser is acting as the Fund Adviser (Discretionary Investment Manager), any fees in respect of this role should be entered in Section F. The Investment Review Fee is a fee agreed between you and your financial adviser. Any payment will be taken as a partial surrender. For clarity, this is not a commission payment. 4 years 5 years Investment Review Fee starting on of % per annum of the value of my Portfolio Fund to be taken quarterly half-yearly subject to a maximum equivalent to 1% per annum or 1.14% if VAT is applicable, and minimum payment of 500, payable once any commission has ceased. yearly Page 5 of 28

6 E Source of funding THIS SECTION MUST BE COMPLETED IN ALL INSTANCES. PLEASE NOTE THIS SECTION CONTINUES ON THE FOLLOWING THREE PAGES. The investment amount will be invested after all requirements have been met and, where applicable after the SARS (South African Revenue Service) Application for a Tax Clearance Certificate has been received. Source of funds Please complete (a) or (b) as appropriate. For Contributions from multiple bank accounts, please photocopy this page and complete for each bank account. (a) Where payment is from a bank account in the name of at least one Contract Holder, please complete the following: Bank account holder (name as stated on bank account) Bank account number/iban* Sort code** (if applicable) SWIFT or BIC code** (if applicable) Bank account currency Bank name Bank address - - Country Postcode How long have you held this account? years months ** IBAN stands for international bank account number and is always used in conjunction with a bank identifier code (BIC). ** A sort code is used in the UK in conjunction with a bank account number. A SWIFT code is used outside Europe in conjunction with a bank account number. A BIC code is used in Europe in conjunction with an IBAN. Would you like to nominate the bank account above as the account to be used to receive payments out? Yes No If you do not wish to nominate the bank account above as the account to be used to receive payments out, you can nominate a different account in your name, below. We will keep those details on our records. Bank account Holder (name as stated on bank account) Bank account number/iban* Sort code** (if applicable) SWIFT or BIC code** (if applicable) Bank account currency - - Bank name Bank address Country (b) Third-party payments, such as payments made by persons other than a Contract Holder, are not normally acceptable. However, we may accept payments in the following situations and with the following additional documentation. Please tick as applicable (3): Payment from another financial services institution, where the previous investment was held either solely or jointly by at least one of the Contract Holders. Copy documentation showing the investment and the payment will be required. (Note: payment from unregulated companies or from certain jurisdictions may not be acceptable.) Page 6 of 28 Postcode Payment by a husband for a Contract in his wife s name and not his own, or vice-versa. A copy of the marriage certificate and of the payor s passport or identity card plus residential address evidence will be required. Payment from a lawyer as a result of an inheritance, a settlement, a property sale, or other legitimate source. A copy of a letter from the lawyer confirming the source of funds will be required.

7 E Source of funding (continued) THIS SECTION MUST BE COMPLETED IN ALL INSTANCES. Employer details Contract Holder 1 Contract Holder 2 (if any) Please give details of your employer or your own company, if self-employed. If you have retired, please include details of your employer or your own company before retirement. Please also enter your final year's salary/income and bonus, if any, before retirement. If there are any further Contract Holders, please photocopy this page, attach details with this application form and tick here (3) Name of employer or your own company Address of employer or your own company Postcode Postcode Country Website address of employer or your own company (if any) Last year's gross salary/ income amount (please specify currency) Last year's bonus amount (if applicable. (please specify currency) Date of retirement Final salary (please specify currency) Full details of origin of wealth PLEASE TICK THE DESCRIPTION OPTION(S) RELATING TO THE ORIGINAL SOURCE OF THE CONTRIBUTION FOR YOUR INVESTMENT PORTFOLIO. YOU MUST FULLY COMPLETE EACH RELEVANT SECTION RELATING TO THE DESCRIPTION OPTION(S) YOU HAVE TICKED. (3) Description Details required Your details Accumulated savings/ investments Amount of savings/investments Savings/investments held for Amount: (please specify currency) years months Details of where funds are held: Account Holder (name as stated on account) Account number Name of financial institution/bank Regular income from employment or Regular income from your business (for example if self-employed) Details of last year s income and bonus as declared under Employer details above Page 7 of 28

8 E Source of funding (continued) THIS SECTION MUST BE COMPLETED IN ALL INSTANCES. Full details of origin of wealth (continued) PLEASE TICK THE DESCRIPTION OPTION(S) RELATING TO THE ORIGINAL SOURCE OF THE CONTRIBUTION FOR YOUR INVESTMENT PORTFOLIO. YOU MUST FULLY COMPLETE EACH RELEVANT SECTION RELATING TO THE DESCRIPTION OPTION(S) YOU HAVE TICKED. (3) Description Details required Your details Sale of shares Maturing investments Policy claim Replacement policy Name of company that held your shares/investment/policy (for example bank, stockbroker or insurance company) Name of person who held the shares/ investment/policy How were they sold? (ie bank, stockbroker or other agent, if applicable) Description of shares sold (if applicable) Reason for policy claim or replacement policy (if applicable) Total amount paid out (please specify currency) Surrender penalty incurred (if any) Date received Shares/investment/policy held for years months Sale of property/interest in company Name of company (if applicable) Address of property/company sold (including postcode if applicable) Nature of business (if company sale) Total sale amount (please specify currency) Amount received: Date of sale Page 8 of 28 continued

9 E Source of funding (continued) THIS SECTION MUST BE COMPLETED IN ALL INSTANCES. Full details of origin of wealth (continued) PLEASE TICK THE DESCRIPTION OPTION(S) RELATING TO THE ORIGINAL SOURCE OF THE CONTRIBUTION FOR YOUR INVESTMENT PORTFOLIO. YOU MUST FULLY COMPLETE EACH RELEVANT SECTION RELATING TO THE DESCRIPTION OPTION(S) YOU HAVE TICKED. (3) Description Details required Your details Other unearned income Inheritance Loan Origin of wealth (if ticked gift or other) From which organisation or whom (state the relationship if applicable) Gift Compensation Details (including reasons where applicable, how the money was acquired, etc) Competition or gambling win Other Amount: (please specify currency) Date received We may also require additional documentary evidence to support your application, particularly in relation to your country of residence, source of funding and investment amount, before we can process it. Your financial adviser can establish if further documentary evidence is needed by contacting us before sending in your Application Form. Please enter what documentary evidence you are enclosing with this Application Form (if applicable). Page 9 of 28

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11 F Appointing a Fund Adviser (also known as a Discretionary Investment Manager) Please tick as appropriate (3) and read Section G 'Fund Adviser' for more information. I have not appointed a Fund Adviser and I will act on an "execution only basis". This means that I, as the Contract Holder, will issue dealing instructions directly to the Authorised Custodian's Dealing Desk (You do not need to complete the rest of this section, but ensure the Letter of Authority, at the end of the application form is completed); or I Contract Holder s name appoint my financial adviser as indicated on page 1 of this Application Form to act as my Fund Adviser; or I Name of Fund Adviser Contract Holder s name appoint a third party, which may be a company linked to the Authorised Custodian, to act as my Fund Adviser as specified below. Address Address Telephone Number The fees (inclusive of any VAT payable) that the Fund Adviser charges for this service are as follows: The payment of the fee is to start: (3) % per annum of the value of my Portfolio Fund to be taken immediately, or quarterly half-yearly yearly in arrears subject to a minimum payment of 500. If the Fund Adviser is also acting as the financial adviser and receiving commission as a result, then the Discretionary Manager Fee is (1) subject to a maximum of 1.14% per annum including VAT ; (2) payable only once the commission payment has ceased. This will be paid by partial surrender of Contracts. on Please note that fees are calculated and paid in Contract Currency unless otherwise requested. If the Fund Adviser is a third party and not the financial adviser, please insert your bank account details below. Bank account holder (name as stated on bank account) Bank account number/iban* Sort code** (if applicable) - - SWIFT or BIC code** (if applicable) Bank account currency Bank name Bank address Postcode Country ** IBAN stands for international bank account number and is always used in conjunction with a bank identifier code (BIC). ** A sort code is used in the UK in conjunction with a bank account number. A SWIFT code is used outside Europe in conjunction with a bank account number. A BIC code is used in Europe in conjunction with an IBAN. Page 11 of 28

12 F Appointing a Fund Adviser (also known as a Discretionary Investment Manager) (continued) Acceptance of appointment I, the authorised signatory for the Fund Adviser named above, agree that: 1. The Fund Adviser has the necessary regulatory permission to carry out this activity and will inform Old Mutual Isle of Man and the Contract Holder if this stops being the case, for example in South Africa this would be a licensed Discretionary Financial Services Provider; 2. The Fund Adviser will be responsible to the Contract Holder for investment decisions in relation to the Investment Portfolio; 3. The Fund Adviser has obtained and read a copy of the General Conditions to familiarise themselves with the responsibilities and requirements of those General Conditions and agrees to act in accordance with them at all times. 4. Where the Fund Adviser is subject to South African regulation, the Fund Adviser and Contract Holder confirm: i. a Mandate has been agreed and signed by the Contract Holder; ii. the Mandate authorises the above named Fund Adviser to act on behalf of the Contract Holder with full discretion. If a limited discretion has been provided Old Mutual Isle of Man and the Dealing Desk will only be able to accept instructions from the Contract Holder. 5. The Contract Holder or I have completed the Letter of Authority form which, once completed by Old Mutual Isle of Man or the Reinsurer, provides the 'Authorised Individual to give instructions to the Authorised Custodian subject to the terms and conditions specified in the Letter of Authorisation. 6. The Discretionary Manager Fee will be taken as a partial surrender in accordance with the General Conditions. If the amount to be paid is below the minimum partial encashment amount then Old Mutual Isle of Man will accrue the calculated value and pay the Discretionary Manager Fee at the earliest opportunity on the Quarterly Date which the minimum partial surrender is met, subject to point 7 below. 7. If the Plan is in the Restricted Period as defined in the General Conditions and no further encashments are allowed at that time then payment of any outstanding Discretionary Manager Fee will have to paid directly by the Contract Holder. Name of Fund Adviser firm Signature Date Name of signatory Position Old Mutual Isle of Man, branch of Old Mutual Life Assurance Company (South Africa) Limited, is registered in the Isle of Man under number F and whose principal place of business is Skandia House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0) Fax: +44 (0) Website Authorised and regulated by the Isle of Man Insurance & Pensions Authority. Old Mutual Life Assurance Company (South Africa) Limited is incorporated in South Africa (reg. number: 1999/04643/06). Registered office: Mutual Park, Jan Smuts Drive, Pinelands, Cape Town, South Africa. Old Mutual Life Assurance Company (South Africa) Limited is a registered long-term insurer and a licensed financial services provider. SK7794/INT11-532/February 2012 Page 12 of 28

13 G Declaration and application THIS SECTION MUST BE READ, UNDERSTOOD AND COMPLETED IN ALL CASES. Application I hereby request my Investment Portfolio to be issued as the number of Contracts specified in Section B. I request that each of these Investment Portfolio Contracts is invested in the Portfolio Fund. I acknowledge that this Application Form and all statements contained herein apply to all such Contracts issued under the Plan and the initial Contribution will be split equally between them. Warranty I warrant that all the information given in this Application Form, and in all documents which have been or will be signed by me in connection with the Contract(s), whether in my handwriting or not, is true and complete. Declarations I understand and agree that: 1. The information provided by me referred to in the Warranty above forms the basis on which Old Mutual Isle of Man decides whether to enter into the proposed Contract(s). 2. Any mis-statement or omission herein may lead to any Contract(s) made being declared void by Old Mutual Isle of Man or the General Conditions being varied by Old Mutual Isle of Man. In such an event, I will not be entitled to more than the Contribution(s) received by Old Mutual Isle of Man minus all charges, costs and currency and/or investment losses incurred. 3. Should this Application Form be accepted by Old Mutual Isle of Man it will be conditional upon there having been no material alteration to the facts on which the acceptance was based. 4. No statement, whether made by myself or by the person canvassing for or handling this Application Form or by any other person, shall be binding upon Old Mutual Isle of Man unless the same be in writing, submitted to Old Mutual Isle of Man and made part of the Contract(s). 5. The Contract(s) will be concluded in the Isle of Man upon acceptance of the application by Old Mutual Isle of Man and will be governed by the laws of the Isle of Man. 6. Communication of acceptance by Old Mutual Isle of Man will not be given and I do not require such communication for the Contract(s) to come into effect. 7. The issuing of this/these Contract(s) creates an estate in the Isle of Man for myself and that Old Mutual Isle of Man reserves the right to receive an Isle of Man Grant of Probate. 8. No representation, guarantee or warranty is made by Old Mutual Isle of Man as to the performance or investment returns of the underlying investment options selected by the Contract Holder(s). Old Mutual Isle of Man shall have no liability to me for any losses suffered by me as a result of my failure: a. To appreciate the nature of investment in the underlying investment options; b. To have read and understood the information provided to me concerning investment in the Contract(s) and its underlying investment options; c. To have acquainted myself with all charges payable in respect of investment in the Contract(s) and its underlying investment options; d. To have obtained (or, having obtained, to have acted upon) advice concerning the appropriateness of the Contract(s) for my financial circumstances (including, but not limited to, the legislative and fiscal regimes of my/our country of citizenship, domicile or residence which might affect the Contract(s) and any benefits payable thereunder); e. To have reviewed regularly the continued suitability of the Contract(s). 9. Due to fluctuations in relative values of international currencies there may be a risk of a reduction in the value of the capital invested when measured in any particular currency and after currency conversions the Contract minimum must be attained as per the Key Features Document. 10. I bear the risk of changes in fund price or foreign exchange rates (if any) which may occur from the date of completion of this Application Form to the date Allocated Units are purchased or Contribution being exchanged to a different currency. 11. Old Mutual Isle of Man will not accept or record a security cession where the cessionary is a South African resident until it is shown to the satisfaction of Old Mutual Isle of Man that the cessionary is in receipt of the requisite tax and South African Reserve Bank clearances. 12. a. A security cession will take precedence over any Beneficiary Nomination received and accepted by us; b. Any absolute assignment will invalidate any Beneficiary Nomination immediately. 13. All contributions and benefits are payable and have to be accepted in the Isle of Man in US Dollars, Euro, Sterling, Australian Dollars or Swiss Francs as denominated in the Contract(s) Summary. 14. Old Mutual Isle of Man s obligation is to pay proceeds to me in the Contract Currency, and that should I request payment outside the Isle of Man and/or in a currency other than the Contract Currency, I assume the risk associated with the transfer and/or currency conversion and any delays which may occur in this process. 15. I bear the risk of the method selected for communicating this application and/or any further application or communication with Old Mutual Isle of Man and that Old Mutual Isle of Man shall not be liable for any loss suffered by me as a result of the use thereof. 16. I am entitled to ask for a copy of this Application Form and I must be given a copy within a reasonable period. Confirmations I confirm that I have received, read and understood the: Product Brochure; General Conditions; Key Features Document and addendum detailing the Authorised Custodian charges. Page 13 of 28

14 G Declaration and application (continued) THIS SECTION MUST BE READ, UNDERSTOOD AND COMPLETED IN ALL CASES. Commission, charges and fees Commission 1. I understand that Old Mutual Isle of Man will pay commission to my financial adviser as indicated in Section D. Old Mutual Isle of Man pays commission for introducing my business to Old Mutual Isle of Man. Investment Review Fee 2. Where indicated in Section D, I have agreed to pay my financial adviser an Investment Review Fee once the commission payments to my financial adviser have ceased. If my Fund Adviser is also acting as my financial adviser and receiving commission as a result, then the Investment Review Fee is (1) subject to a maximum of 1.14% per annum including VAT ; (2) payable only once the commission payment has ceased. 3. I instruct Old Mutual Isle of Man to disinvest enough of the Portfolio Fund value on the frequency stated and pay this fee to my financial adviser on my behalf for as long as this instruction remains in force. 4. I understand that Old Mutual Isle of Man can only pay this fee provided the financial adviser has terms of business with Old Mutual Isle of Man and there is no legal or other limitation on disinvestments from my Plan. 5. Should there be a limitation on payment from my Plan then I will pay my financial adviser myself. 6. I pay my financial adviser an Investment Review Fee for providing me with ongoing annual advice and understand this is treated as a partial surrender. Advice fee (Charging Option 2 only) 7. Where indicated in Section D, I have agreed to pay an Advice fee to my financial adviser for providing me advice to purchase this Plan. 8. I instruct Old Mutual Isle of Man to deduct this Advice fee from the amount I pay and to pay this fee to my financial adviser on my behalf prior to the investment being made with Old Mutual Isle of Man. Authorised Custodian I confirm that: 1. I have obtained, read and understood all relevant documents regarding the Authorised Custodian including details of the services and charges that apply. 2. I understand and agree that Old Mutual Isle of Man or the Reinsurer bears no legal or other responsibility if at any time the authorised custodian: i fails to meet any of its obligations; and/or ii acts in a fraudulent, incompetent or negligent manner; and/or iii enters into liquidation and/or receivership or enters into a voluntary arrangement with its creditors and/or is unable to pay its debts. 3. By making this request to Old Mutual Isle of Man or the Reinsurer to appoint the Authorised Custodian I understand that I shall not be entitled to make any claim against Old Mutual Isle of Man or the Reinsurer relating to the custody of the investments of my Portfolio Fund irrespective of any express or implied obligation that exists in the General Conditions. 4. I understand that any Authorised Custodian charges will be deducted by Old Mutual Isle of Man from the Portfolio Fund. 5. I agree that Old Mutual Isle of Man or the Reinsurer can release my personal data to the Authorised Custodian should it be required to do so by the Authorised Custodian to enable it to comply with local laws or anti-money laundering practices. 6. I understand that all investment instructions must be sent to the Dealing Desk at the Authorised Custodian and any investment instructions sent to Old Mutual Isle of Man Head Office will not be actioned. Fund Adviser Where I have appointed a Fund Adviser, I confirm that: 1. I appoint the above named Fund Adviser to act as my agent to provide investment advice to me. Where indicated I request Old Mutual Isle of Man and/or the Dealing Desk to accept investment instructions directly from the Fund Adviser. Old Mutual Isle of Man confirm by providing details of the Fund Adviser to the Dealing Desk that Old Mutual Isle of Man or their Reinsurer confirm the Fund Adviser is able to act in relation to the account which has been referenced to the Contract Holder(s). 2. I have agreed with my Fund Adviser the investment objectives and risk profile for my Investment Portfolio. This has been documented in the investment mandate between me and my Fund Adviser. I understand that it is my responsibility to monitor and manage my relationship with, and the performance of, the Fund Adviser. Old Mutual Isle of Man or their Reinsurer is in no way responsible for the acts or ommissions of the Fund Adviser. 3. Old Mutual Isle of Man will not be responsible for any of the consequences arising as a result of the Fund Adviser's exercise or failure to exercise any options or acting outside the limits of a mandate, a letter of authorisation or terms of business, or not having, or losing, any necessary authorisation. 4. I understand that the Dealing Desk will act exclusively upon the instructions of the Fund Adviser unless and until I have revoked these powers by written notice received by Old Mutual Isle of Man at its head office, as defined in the General Conditions. 5. The Fund Adviser and I have terms of business which detail their roles and responsibilities. I have read and understood these. I also confirm my Fund Adviser has explained and we have agreed the charges and fees set out in Section F. 6. i. If my Fund Adviser is licensed in terms of the Financial Advisory and Intermediary Services Act 2002 (FAIS) then I have signed a Mandate as provided for in the relevant FAIS code of conduct. ii. The Mandate authorises the named Fund Adviser in Section F to act on behalf of the Contract Holder with full discretion. If a limited discretion has been provided Old Mutual Isle of Man and the Dealing Desk will only be able to accept instructions from the Contract Holder. 7. My Fund Adviser or I have completed the Letter of Authority form which, once completed by Old Mutual Isle of Man or their Reinsurer, provides the 'Authorised Individual' to give instructions to the Authorised Custodian subject to the terms and conditions specified in the Letter of Authorisation. 8. Discretionary Manager Fee i. Where indicated in Section F, I have agreed to pay my Fund Adviser a Discretionary Manager Fee. ii. I instruct Old Mutual Isle of Man to disinvest enough of the Portfolio Fund value on the frequency stated and pay this fee to my Fund Adviser on my behalf for as long as this instruction remains in force. iii. I understand that Old Mutual Isle of Man can only pay this fee provided there is no legal or other limitation on disinvestments from my Plan. iv. Should there be a limitation on payment from my Plan then I will pay my Fund Adviser myself and understand this will be treated as a partial surrender. Page 14 of 28

15 G Declaration and application (continued) THIS SECTION MUST BE READ, UNDERSTOOD AND COMPLETED IN ALL CASES. Investment Risk 1. I acknowledge that by requesting to invest in the Investment Portfolio I accept the investment risk. 2. I have acquainted myself with and understood: i. The Assets available, their associated risk ratings and risk factors; ii. The unique characteristics, liquidity constraints, notice periods and risk warnings associated with Assets that invest in alternative investment strategies; iii. All charges taken by Old Mutual Isle of Man, my financial adviser, the Authorised Custodian and where applicable the Fund Adviser. 3. I have been advised, and accept that: i. by asking Old Mutual Isle of Man either directly or through my Fund Adviser to include an Asset in my Portfolio Fund, I agree to accept the risk that, for any reason whatsoever, management of the Asset may not be in accordance with its objectives and parameters. This includes negligent and fraudulent activity. In addition I accept any risk entailed in any change to such objectives and parameters and that it is my personal responsibility to monitor the fund or deposit to which I am invested. The value of shares and units can fall as well as rise and they, as well as bank deposits and any balance on the Transaction Account held with Old Mutual Isle of Man or the Authorised Custodian, could in exceptional circumstances become valueless either temporarily because of suspension, or permanently. In the event of the insolvency of the Authorised Custodian, any cash held by them may be at risk. The fact that Old Mutual Isle of Man may allow or refuse a particular external fund or bank deposit as an Asset does not indicate any judgement by Old Mutual Isle of Man about its investment potential or the propriety of the provider of the Asset. ii. The Investment Portfolio may: a. be invested in a variety of Asset classes and depending on the Assets selected they may: - carry no underlying guarantees and - be at risk of reduction in the value of the capital invested - have limitations on liquidity. b. invest in Assets which have redemption restrictions applied from time to time. If such restrictions are applied this may significantly delay the processing of encashments, benefits and claims. iii. Past performance of the Assets is not a guarantee for future returns. 4. I understand that investments in the alternative investment strategy funds expose investors to additional risks that are not normally associated with investments in traditional asset class funds and are only suitable for the sophisticated investor who is able to and willing to accept the risks associated with such an investment, including a substantial or complete loss of capital. 5. I may wish to invest into professional/non-retail type investment schemes and, if so, I will make sure that I have had the opportunity to read the offering documents for funds of this nature. Where I decide to invest in professional/non-retail type investment schemes, I accept the levels of risk associated with these, including the risk that the investment into such scheme could result in a loss of a significant proportion, or all of the sum invested. I confirm that I am aware of the fees (if applicable) payable for the chosen investment(s) to be held in my Investment Portfolio. I understand that the fees exist partly to meet promotion and distribution expenses of the product, including commission paid to a financial adviser and/or Fund Adviser. Country Specific 1. I acknowledge that the Contract shall be interpreted in accordance with and governed by the law of the Isle of Man and shall comply with applicable South African legislation, rules and regulatory requirements. 2. I am not a national or resident in the United States of America and its territories. 3. This/These Contract(s) is/are not available in the United States of America, its territories and possessions, nor is the Contract(s) available to US residents. Any Contract Holder(s) who later becomes resident in the United States of America, its territories and possessions, will be subject to restrictions placed on the Contract(s). For the duration of residence, these restrictions include the suspension of the ability to buy or sell Assets. Data Protection I consent to my personal data being used in accordance with the Personal Data Statement. Right to Cancel 1. I acknowledge that I am able to cancel this/these Contract(s) during a 30-day period from receipt of the Plan Summary that will be sent to me together with the General Conditions governing the Contract(s). This right shall be exercised by giving written notice to Old Mutual Isle of Man, Skandia House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. In such an event, I will not be entitled to more than a refund of any Contribution, less a deduction for any shortfall resulting from a fall in the markets during this period, any loss as a result of exchange rate movements, any market value adjustor on fixed rate accounts and charges incurred. This option is not available where, during the 30-day period, I have bought or sold Assets and/or any benefit has been paid or claimed. 2. I understand and accept that the following process will apply to a request to withdraw from this/these Contract(s), in terms of this clause: a. All Assets will be encashed after the date the above written notice is received and accepted by Old Mutual Isle of Man, and subject to the conditions applicable to the Assets chosen, including any restrictions on the timing of encashments; b. Payment will only be made to myself after a minimum period of 40 calendar days after the acceptance of the applicable Contribution. However the payment may be significantly delayed should a redemption restriction apply to the Asset(s) I have selected; c. No interest or return of whatever nature will be paid and/or accrue to me on the amount encashed during the period from date of encashment to date of payment to me; d. Where Old Mutual Isle of Man assisted me in converting cash from a currency other than the Contribution Currency, I hereby authorise Old Mutual Isle of Man to convert Assets encashed back to the original currency and pay that money to me. I accept all liability for all costs so incurred and for the risk of any changes in foreign exchange rates; e Where Old Mutual Isle of Man agreed to payment of all or part of my Contribution by a transfer into Old Mutual Isle of Man s ownership of units or shares in an Asset, Old Mutual Isle of Man may transfer those assets into my legal ownership in order to fulfil all or part of my cancellation request. Page 15 of 28

16 G Declaration and application (continued) THIS SECTION MUST BE READ, UNDERSTOOD AND COMPLETED IN ALL CASES. Complaint Resolution Process Old Mutual Isle of Man provides a complaint resolution process which aims to address any dissatisfaction you may have with your transaction. You can write to Old Mutual Isle of Man, Skandia House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Assurance Replacement Policy These questions must always be answered by the Contract Holder. To 'replace' an existing insurance policy means to terminate or vary existing insurance policy as a result of cancelling or lapsing it, reducing the premiums, making it paidup, reducing the term or surrendering the policy in part or in full. Is this application to replace the whole or part of any of your existing insurance policy with any insurer (i.e. whether the replacement is to occur immediately, to replace an investment that you discontinued in the past four months or that you will discontinue in the next four months)? (3) Yes No If the answer is Yes, the financial adviser must discuss, complete and sign the Replacement Policy Advice Record (RPAR) and attach it to this Application Form. Personal Data Statement Consent by the Contract Holder(s) To: Old Mutual Isle of Man I agree that you may use my personal data, including any sensitive personal data, ( my data ) to process my application and to service my Contract or Contract s ( my Contract ) for the purposes detailed below. I understand and agree that: you may provide my data, by electronic or other means, to: other companies within the Old Mutual Group and the Reinsurer if you regard this as necessary to service my Contract; my financial adviser and Fund Adviser; a third party to verify my identity in line with anti-money laundering or other requirements. This may involve carrying out checks with credit reference databases; reinsurers and other third parties who perform tasks for you to help you service my policy, including amongst other things, hosting my data, and the payment and reporting of any tax or levy. These third parties may be based in the United Kingdom or in countries outside the European Economic Area (EEA). I understand that these countries may not have laws to protect my data equivalent to those of the Isle of Man. However, I understand that you will ensure that any such third parties agree to treat my data with the same level of protection as if you were dealing with it. to prevent and detect financial crime, you may: share my data with other organisations, including law enforcement authorities; check and/or file my data with financial crime prevention agencies and databases. you and other companies within the Old Mutual Group may use my data for assessment, statistical analysis purposes and market research. my data may be made available to third parties where required or permitted by law, court order or regulation. on payment of a small fee, I am entitled to receive a copy of my data, subject to data protection law. I also have the right to require you to correct any inaccuracies in my data. In such circumstances please write to: The Data Protection Officer, Old Mutual Isle of Man, Skandia House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. I CONFIRM THAT I HAVE READ AND UNDERSTOOD SECTION G IN ITS ENTIRETY AND UNDERSTAND ITS IMPLICATIONS. Signature(s) of Contract Holder(s) Signature of Contract Holder 1 Date Country where signed Signature of Contract Holder 2 Date Country where signed If there are more than two Contract Holders, please attach a further copy of this page to the application. Signature of financial adviser I declare that to the best of my knowledge and belief, the information provided in this Application Form is true and complete. Signature of financial adviser Date Print name Page 16 of 28

17 H Verification of customer identity financial adviser to complete THIS SECTION MUST BE COMPLETED IN ALL INSTANCES. Please note that we will not be able to set the Plan live until this section has been completed and you have provided the necessary identification documentation. Outlined below are the standard minimum requirements. In some circumstances we may need additional information. We require one document from part A and one from part B. Identification documentation should be current and valid. Evidence of address should be the latest available, but no more than three months old. Please tick (3) to indicate the identification you have supplied for each individual party to the Plan. If a Fund Adviser has been appointed we may need to verify the identity of the appointee. If there are more than two Contract Holders, please attach a further copy of this page to the application. Part A Individual whose identity is being verified 1. Name Capacity Type of document Passport National Identity Document Document reference 2. Name Capacity Type of document Passport National Identity Document Document reference Reason why documents are not provided (if applicable. If documents are not provided, this will delay the application.) Part B Individual whose identity is being verified These must be no more than three months old A recent utility, rates or council tax bill (cell phone bills not acceptable) 2. A recent mortgage statement, evidencing the residential address 3. A state pension, benefit or other government produced document showing benefit entitlement 4. A recent tax assessment document 5. A recent account statement from bank or credit card (store cards not acceptable) 6. Proof of ownership or rental of the residential address Part C Financial crime risk rating Please refer to the Origin of Wealth Guidelines (available from Old Mutual Isle of Man) for information on how to complete the table below. To prevent financial crime, Isle of Man licenced entities may adopt a risk-based approach when obtaining evidence of the origin of a client s wealth. In order to speed up the application process we have provided you with the table below to allow you to find out your client's risk rating before submitting the Application Form to us. We highly recommend that you complete the risk rating as it allows you to determine if you need to enclose further documentary evidence with the Application Form or not. If we do not receive the necessary documentary evidence with the Application Form, then it will take longer to process the business. In order to decide what risk rating applies to your client s investment you need to take into account the following factors: (a) your client s country of residence (b) which country the contribution is paid from (a) + (b) = total risk rating Contract Holder Client country of residence (a) Country of premium funding (b)* Total risk rating Example South Africa (1) Mauritius (2) (3) * If paying from multiple jurisdictions, the country of funding rating needs to reflect the highest rated country. Old Mutual Isle of Man reserves the right to request further documentation if it is felt appropriate. Please note that each new application, or application for an additional investment, will be reviewed individually. If you are unsure about a particular application, please contact your Offshore Specialist or your local office. Page 17 of 28