Discovery Retirement Optimiser

Discovery Retirement Optimiser Contact details Tel: 0860 67 5777, PO Box 653574, Benmore 2010, www.discovery.co.za How to complete this application form This form needs to be completed for your Discovery Retirement Optimiser. To enable Discovery to process this application form promptly and accurately, please ensure that it is completed in full and that you submit all required documents with the application form. 1. Please complete the form in black ink and print clearly. 2. Write one letter per block. 3. Where you need to make a choice between different options, please mark your selection with an X. 1. Beneficiaries to whom the proceeds of the Discovery Retirement Optimiser will be paid on the death of the principal life/investor You may nominate one or more persons or institutions or beneficiaries to receive the benefits of the Retirement Plan in the event of your death. However, the Pension Funds Act (section 37C) requires the board of trustees of the Discovery Retirement Annuity Fund and the Discovery Invest Retirement Annuity Fund to distribute the benefits equitably between your dependants and your nominated beneficiaries in the event of your death. This beneficiary nomination will assist the board of trustees in making their decision. General If you are married in community of property, consent is needed from your spouse to nominate a beneficiary other than your spouse. If you do not obtain your spouse s consent, he/she may be entitled to claim a share from you if your joint estate is divided. If this applies to you, you must complete the standard Discovery Invest Request to change details form. Please review your beneficiary nomination regularly to take account of changed circumstances. You can change the beneficiary nomination or add more beneficiaries at any time by completing and submitting the Request to change details form, which is available on www.discovery.co.za Please complete the details of the beneficiaries you wish to nominate: 1. Beneficiary: Legal entity Natural person Percentage allocation % Full name Date of birth Y Y Y Y M M D D ID/company registration number Passport number Nationality of passport Relationship Sex M F 2. Beneficiary: Legal entity Natural person Percentage allocation % Full name Title Date of birth Y Y Y Y M M D D ID/company registration number Passport number Nationality of passport Relationship Sex M F 3. Beneficiary: Legal entity Natural person Percentage allocation % Full name Title Date of birth Y Y Y Y M M D D ID/company registration number Passport number Nationality of passport Relationship Sex M F Title Page 1 of 8 121358 (T17313) LFEE 2245 (V4) 11.15

2. Product details Source of funds: Income Donation Other Monthly contribution Date of commencement Y Y Y Y M M D D Retirement age Contribution waivers on Retirement Investment Integrator Retirement PayBack Booster R (Choose any age from 55.) (backdating is not allowed) Disability of principal life or investor Severe illness of principal life or investor Disability and severe illness of principal life or investor As a Discovery Life Plan policyholder, you may qualify for the Retirement Investment Integrator, which will give you a reduction of all Discovery Invest annual administration fees, policy fees and fund management fees. Discovery Life Plan policy number (if different to the Life Plan being applied for with this application) As a Discovery Classic Life Plan policyholder, you may qualify for the Retirement PayBack Booster, which boosts your Health or Vitality PayBack if it is invested into your Discovery retirement Optimiser. How much of your PayBack would you like to invest? None Half my PayBack My full PayBack In this case, Discovery will debit your account after the Health or Vitality PayBack has been paid. Refer to section 5.4. Pre-existing exclusion clause: All claims arising from any physical defects, illnesses, bodily injuries or diseases the life assured has suffered from, was aware of, or has received medical treatment for, or any circumstances which have or are likely to have an adverse effect on the health of the life assured, before the commencement of the Discovery Retirement Optimiser, are excluded for the Contribution Waiver Benefit and the Ill-Health Income Booster. 3. Investment fund selection Please complete the fund names in full with your investment choice options. You will find detailed information about the investment choices in the latest fund selection list available on www.discovery.co.za Percentage of net investment 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Total 100% 4. Statutory disclosure and terms and conditions 4.1 Statutory disclosure Net asset value (NAV) All prices are calculated on a NAV basis. NAV is the total value of all assets in a portfolio, including any income accrual and less any permissible deductions from the portfolio divided by the number of units or participatory interests in issue. Permissible deductions include brokerage, Uncertified Security Tax (UST), auditor s fees, bank charges, trustee or custodian fees and the service charge levied by Discovery Life Collective Investments (Pty) Ltd. Upfront manager charges The upfront manager charge is deducted from the full investment value and the remaining amount is allocated to the client s selected investment options. Any additional investment will incur an upfront manager charge. The charges range from 0% to 0.57%, depending on the relevant investment chosen. Service charge The annual service charge for the individual portfolios is accrued daily and levied monthly on the market value of the fund or portfolio. The annual service charge is deducted from the income received by the portfolios. Total expense ratio (TER) The total expense ratio or TER of a portfolio is a measure of a Fund s assets that have been surrendered as payment for costs of management, which is expressed as a percentage of the daily average value of the portfolio and is calculated over a period of usually a financial year. Switching A switch involves selling the participatory interest in one portfolio and allocating and investing the proceeds in another portfolio. Discovery will waive the first four voluntary switch fees, thereafter a fee of 0.25% of the amount switched will be charged. Page 2 of 8

4. Statutory disclosure and terms and conditions (continued) Income distributions Income distributions are made at regular intervals of all portfolios and may vary depending on the chosen portfolio. Portfolios either declare distributors monthly, quarterly (31 March, 30 June, 30 September, 31 December), bi-annually (30 June, 31 December) or annually (31 December). These distributions are paid by no later than the last working day of the following month. Fee rebate Discovery Invest may receive fee rebates from certain investment managers from time to time. These rebates will be passed on to investors by purchasing additional units that will be added to the investor s portfolio. Electronic transactions Discovery will be entitled to implement all instructions and applications received by them on their internet site, by telephone, fax or any other electronic medium and that appear to emanate from the investor. Discovery is indemnified against any such losses, claims or damages that arise from acting on instructions received via these forms or any other electronic mediums processed on behalf of the investor or that purport to be processed on behalf of the investor, even if it may later be proved that any such instructions were not given by the investor. General 1. Collective investment schemes in securities (CIS) are generally medium- to long-term investments. 2. The value of participatory interests may go down or up and past performance is not necessarily and indication of future performance. 3. Actual investment performance will differ based on the initial fees applicable, the actual investment date and the date of reinvestment of income. 4. Fluctuations or movements in exchange rates may cause the value of underlying investments to go up or down. 5. Fund prices are published each business day (with a three-day lag) on www.discovery.co.za 6. With regard to the Money Market portfolio, the price of each unit is aimed at a constant value. Excessive withdrawals from the portfolio may place the portfolio under liquidity pressures, and in such circumstances a process of ring-fencing of withdrawal instructions and managed payouts over time may be followed. The Money Market portfolio is not a bank deposit account. The total return to the investor is primarily made up of interest received, but may also include any gain or loss made on any particular instrument. In most cases this will merely have the effect of increasing or decreasing the daily yield, but in extreme cases it can have the effect of reducing the capital value of the Fund. 7. CIS are traded at ruling prices and can engage in borrowing and scrip lending. 8. A schedule of fees and charges and maximum commission is available on request from Discovery Life Collective Investments (Pty) Ltd. 9. The Manager may borrow up to 10% of the market value of the portfolio to bridge insufficient liquidity. 10. Commission and incentives may be paid and if so, would be included in the overall costs. 11. The exposure limit to a single security in certain portfolios can be greater than is permitted for other portfolios in terms of the Collective Investment Schemes Control Act. Details are available from the Manager. 12. Forward pricing is used. Fluctuations or movements in exchange rates may cause the value of underlying investments to go up or down. 13. A fund of funds is a portfolio that invests in portfolios of collective investment schemes that levy their own charges, which could result in a higher fee structure for these portfolios. 14. A feeder fund is a portfolio that invests in a single portfolio of a collective investment scheme, which levies its own charges, which could result in a higher fee structure for the feeder fund. 15. The Manager reserves the right to close certain portfolios to new investors in order to manage the portfolio more efficiently in accordance with its mandate. More details are available from the Manager. 16. The holding of offshore investments in certain portfolios is subject to current South African Reserve Bank (SARB) regulations. 17. Where foreign securities are included in the portfolio, any material risks will be included in the fund fact sheets. 18. Any capital gain realised on the disposal of a participatory interest in a CIS will be subject to Capital Gains Tax (CGT). 19. All portfolios are valued on a daily basis at 16:00, except at month end, when portfolios are valued at 17:00. Investments and repurchases will receive the same price for that day if received before 11:00 for the Money Market portfolio and 15:30 for the other portfolios. 20. The investor confirms that neither Discovery Life Collective Investments (Pty) Ltd or any staff provided them with any advice (as defined in the FAIS Act) and that they have taken particular care to consider on their own or with the assistance of their financial adviser whether the investment chosen is appropriate considering their individual needs, personal objectives and financial situation. Discovery Life Collective Investments (Pty) Ltd (the Manager) is a member of the Association of Savings and Investments SA (ASISA). Manager Trustees Discovery Life Collective Investments (Pty) Ltd Standard Chartered Bank 155 West Street, Sandton 2196 Johannesburg Branch, 4 Sandown Valley Crescent, Sandton 2196 Telephone: 0860 67 5777 Telephone: 011 217 6600 4.2 Terms and conditions 1. What we mean by certain words 1.1 When we use the term Discovery, we include Discovery Invest and Discovery Life. 1.2 When we use the term Fund, we mean the Discovery Retirement Annuity Fund (37469). 1.3 When we refer in the terms and conditions that follow to the products, we mean the Discovery Retirement Optimiser. 1.4 Where we refer to investor, we mean the person who invested in the product or the owner of the investment. This could be the principal life of the Discovery Life Plan. 1.5 Where we refer to life assured, also known as the insured, we mean the person whose life event will determine the provision of benefits by the insurer. 2. Licences and authorities 2.1 The products are administered by either Discovery Invest or Discovery Life. 2.2 Discovery warrants that it holds professional indemnity and fidelity insurance cover as required by the Financial Advisory and Intermediary Services Act (FAIS Act). 2.3 Discovery reserves the right to accept or reject the investor s application form and subsequent transactions or instructions and will not enter into any discussion with regard to accepting or rejecting the application and subsequent transactions or instructions. 2.4 The products and agreements entered into by Discovery in respect of any investment options are subject to all statutory and regulatory requirements. 2.5 The Fund is registered by the Financial Services Board (FSB) in terms of the Act and approved by SARS in terms of the Income Tax Act. 2.6 The Fund is managed by a Board of Trustees. In terms of the Act, when performing its functions, this Board of Trustees must act in accordance with the fiduciary duties owed to the Fund and the duty of care and good faith owed to the members and other beneficiaries of the Fund. 3. Financial advisers 3.1 If Discovery is not the appointed financial adviser then Discovery does not provide any advice to the investor. 3.2 Discovery will only allow financial advisers who are authorised and licensed by the Financial Services Board (FSB) to act as financial services providers on behalf of investors, to advise the investor in making the appropriate investment choices. 3.3 Unless the financial adviser is an employee of Discovery, the investor cannot hold Discovery responsible, accountable or liable for suffering any loss or damage if the financial adviser is not authorised as a financial services provider, and the processing of this application form is delayed and afterwards rejected because of that fact. 3.4 Financial advisers have the responsibility to act within their licence conditions and authority. Unless the financial adviser is an employee of Discovery, the investor cannot hold Discovery responsible or liable for suffering any loss or damage as a result of the financial adviser acting outside the scope of his or her authority and licence conditions. Page 3 of 8

4. Statutory disclosure and terms and conditions (continued) 3.5 The financial adviser must ensure that the investor receives and understands all appropriate advice, product and fee information. 4. Documents the investor can expect from us On commencement of the investment, we will email certain documents to the investor. These include a summary of the personal and investment details and investment choices and an investment fact file. If we don t have a direct email address, we will post the documents to the investor. The investor has 10 business days from receipt of the documents to inform us if any of the personal or investment information is incorrect. 5. Communication between the investor and Discovery 5.1 To process any instruction on a specific day, Discovery must receive the instruction before 10:00; otherwise the instruction will only be processed on the following business day. (Any instruction so received will only be processed once the money reflects in the relevant bank account, has been matched and all documentation and proof of the deposit or electronic funds transfer [EFT] have been received by Discovery). This may take up to 24 hours to process. 5.2 We may communicate with the investor electronically unless otherwise specified. 6. Investment options and performance 6.1 Discovery is not held responsible or liable for any losses incurred due to delays, oversight or any other errors attributable to the manager of any investment options and any losses or harm the investor may suffer directly or indirectly as a result of occurrences relating to the investment that are beyond their control. 6.2 If any statutory or regulatory requirements impact the return generated by any investment options, Discovery or the Fund reserves the right to revise the value of the investment accordingly and the investor will have no recourse against Discovery or the Fund. 6.3 Please note that if any investment options selected have been capped, the investment amount specified for the capped investment option will default to the Discovery Money Market Fund until Discovery is notified of an alternate investment choice. The details of the capped investment option will be communicated to the investor if this happens. 6.4 Discovery or the Fund does not guarantee the performance of the investment instruments or investment options. The Board of Trustees of the Fund have an obligation to monitor the performance of the investment options or investment instruments. If the Trustees of the Fund are of the opinion that the investor s share should not be invested in any investment instrument or investment option, or if the Trustees of the Fund are of the opinion that it would be in the Funds best interest to stop investing in any investment instrument or investment option, they will let the investor know and the investor will have to select an alternative investment option or investment instrument. 6.5 The investor acknowledges that any funds of a collective investment scheme forming part of the portfolio selected within the Fund do not constitute assets the investor owns, but rather that Discovery and/or the Fund owns and that Discovery and/or the Fund participates in these funds. Accordingly, the prices of units of such collective investment scheme funds published in newspapers cannot be directly correlated to the unit prices of the selected portfolio. 6.6 If Discovery is obliged to remove or withdraw some or all of the funds from an investment option in order to comply with statutory or regulatory requirements, then such funds will be invested into the Discovery Money Market Fund until the investor notifies Discovery of another investment option. Discovery or the Fund will not be liable for any loss or harm the investor may suffer as a result of such withdrawal and subsequent investment into the Discovery Money Market Fund. 6.7 All income earned on the investment options will be automatically reinvested in the same investment option until Discovery receives instructions from the investor. 7. Escalator funds (if applicable) 7.1 Escalator funds include a riskier asset and a cash component. The value of the fund at any time is based on the market value of both the underlying riskier asset and the cash component. 7.2 The 80% Dynamic Market Value guarantee level is based on the overall value of each Escalator Fund and not on the value of the riskier asset only. The guarantee applies at all times and not only at the end of a specified time period. 7.3 For Geared Escalators, the exposure to the riskier asset may exceed 100%. This additional exposure is achieved by effectively borrowing money. If the additional growth on the additional exposure is less than the interest rate on the borrowed component, the overall fund value will decrease. 8. Legislative investment limitations 8.1 In terms of the Pension Funds Act and Exchange Control Legislation, the Fund may not invest more than 75% of its total assets in shares and more than 15% of its total assets offshore. The Fund s investment rules allow for members to invest freely in terms of their investment objectives. Members are advised however, that if the Fund exceeds any of the legislative investment limitations, the Trustees may implement such remedies as they deem equitable (ensuring parity of treatment between members). These remedies may include obliging members to proportionately reduce their share and offshore exposure by investing in other unit trusts. As far as possible, the Fund allows members investment choice, but if legislative investment limits are exceeded,the Trustees and members are jointly responsible for ensuring compliance to the investment limits. Members are accordingly advised to regularly review their portfolios with their authorised financial service provider. 8.2 Discovery will not be liable for any loss or harm suffered directly or indirectly as a result of the Trustees implementing such remedies they deem necessary to comply with the Pension Funds and Exchange Control Legislation. 9. Membership of the Retirement Annuity Funds 9.1 When the investor makes a contribution to the Fund, the investor becomes a member of the Discovery Retirement Annuity Fund number 37469 (the Fund). On acceptance, the investor will be bound by the Fund rules. 9.2 The Discovery Retirement Annuity Fund is a retirement annuity fund registered by the FSB in terms of the Pension Funds Act and approved by the South African Revenue Service (SARS) in terms of the Income Tax Act. 9.3 The Fund is managed by a Board of Trustees. In terms of the Pension Funds Act, when performing its functions, this Board of Trustees must act in accordance with the fiduciary duties owed to the Fund and the duty of care and good faith owed to the members and other beneficiaries of the Fund. 9.4 The membership of the Fund begins if Discovery (acting as the Fund s appointed administrator) has confirmed to the investor, in writing, that their application for membership has been accepted, and that the first contribution has been received. 9.5 The investor will be bound by the Fund rules, the Act, this application form, the investment fact file and all other business practices of Discovery. 9.6 Tax in accordance with the applicable tax rules and rates, as determined by SARS, will be applied on any lump sum. The registered insurer from whom the Fund will purchase an annuity in the name of the investor will be obliged to deduct tax from any annuity payment it makes to the investor. 10. Contributions to the Retirement Plan 10.1 Once the investor has become a member of the Fund, the Fund will invest all contributions paid by the investor within four working days of receipt of the contributions and acceptance of the application by Discovery. 10.2 Once the investor has made a contribution to the Fund, the contribution cannot be refunded to the investor. 10.3 The investor may choose how the contributions to the Fund are to be invested. If an investment option is not chosen on the application form, or if the investment option details are unclear, or if the investment option chosen by the investor is no longer offered, or if no written instructions regarding the investment options have been received from the investor, all contributions will be placed in the Discovery Money Market Fund until a valid instruction is received from the investor or the financial adviser. Discovery is not liable for any loss the investor may suffer as a result of Discovery placing the contributions in the Discovery Money Market Fund in terms of this paragraph. Page 4 of 8

4. Statutory disclosure and terms and conditions (continued) 11. Benefits payable 11.1 The benefit in the Fund (referred to as the member s interest in the Fund rules) cannot be ceded, transferred, assigned, reduced, hypothecated or pledged and is subject to the provisions of the Pension Funds Act and other applicable legislation. 11.2 At the selected retirement date, the Fund rules and the Income Tax Act provide that the investor may take up to 1/3 of the benefit as a cash lump sum, and that the balance of the benefit must be used to purchase an annuity from a registered insurer in terms of the Long-term Insurance Act. 11.3 On retirement (including ill-health retirement) the investor accrues a right to an annuity. The amount of the annuity depends on the value of the investment options selected by the investor as at the date of the retirement. 11.4 The investor can only receive the benefits due in the event of the investor s death or retirement. This includes retirement due to ill-health where the investor is able to prove, to the satisfaction of the Board of Trustees, that he or she is medically disabled and qualifies for a disability benefit in terms of the Fund rules. In the event the investor s retirement, the investor may receive the full amount in cash, if the value of the investment is less than R75 000. 11.5 The investor can retire from the Fund at any time from the age of 55, apart from for the reason of ill-health, in which case the investor can retire at any age. 11.6 The benefit or right to the benefit from the Fund is subject to sections 37A and 37B of the Act. The investor cannot use the benefit or right to the benefit as security or transfer it to someone else or make it over to a third party. The investor s creditors cannot attach the benefit or right to the benefit. 11.7 The investor may also withdraw their funds before retirement, provided that their Fund is less than R7 000. 11.8 In the event of the investor s death, the benefit payable by the Funds is subject to section 37C of the Pension Funds Act. In essence, this section of the Act gives the Board of Trustees discretion, which must be equitably exercised with regard to who should receive the benefit. The Act provides that dependants, as defined in the Act, and beneficiaries as nominated in writing by the investor, can receive the benefit. If the investor does not have any dependants and has not nominated a beneficiary, then the benefit will be paid into the investor s estate. 11.9 If the investor dies before the retirement date, in terms of the Fund rules and the Pension Funds Act, the Board of Trustees of the Fund must distribute the benefits in whatever proportions they consider equitable between the dependants and/or nominated beneficiaries of the investor, who may not necessarily be the same person. 11.10 Important: In terms of the Fund rules, the Board of Trustees of the Fund must consider the dependants of the investor even though they may not have been nominated as beneficiaries. 11.11 No statement made by the investor or the person canvassing for or handling this application or by any other person will be binding on Discovery and/or the Fund unless the statement is in writing, submitted and accepted by Discovery and/or the Fund. 12. Transfer to other retirement annuity funds The investor may transfer the Fund benefits to another approved retirement annuity fund registered with the FSB and SARS, provided that the transfer complies with the applicable fund rules and regulations governing the transfers between such retirement annuity funds. The amount the investor transfers will be the member s share as defined in the Fund rules. Before the investor transfers the benefit in the Fund to any other retirement annuity fund, it is recommended that the investor get specific advice about the tax consequences of the proposed transfer. 13. Withdrawal of access Discovery reserves the right to withdraw the access of the investor to investments of a particular external manager s funds, including collective investment schemes, if such fund manager or collective investment scheme has notified Discovery that it will not accept further investments in one or more funds under its management, Discovery may then allocate the contributions to the Investment Solutions Banker fund or any other funds Discovery may make available. Discovery or the Fund or both of them will not be liable for any loss or harm suffered directly or indirectly as a result of the withdrawal of the access of the investor investments to the external manager s funds or collective investments schemes. 14. Activation after debit order date If in the event that this investment contract is activated after the debit order date selected, the Discovery retirement Optimiser Benefit will take effect on the first of the following billing month. 15. General terms and conditions for the Retirement Investment Integrator (if applicable): 15.1 Applies only to certain funds as defined by Discovery and does not apply to external funds. 15.2 Applies as long as the Discovery Life Plan remains in force and the Retirement Plan is not surrendered. 15.3 Is available only to natural persons or Trusts with a natural person as the beneficiary. 15.4 The discounts may change with changes to the Retirement Annuity monthly contributions. 16. General terms and conditions for the Contribution Waiver Benefit 16.1 The Contribution Waiver Benefit is underwritten by Discovery Life and is governed by the Long-term Insurance Act. 16.2 Only natural persons can apply for the Contribution Waiver Benefit. 16.3 For full details about the Contribution Waiver Benefit, please refer to the investment fact file or contact Discovery or the financial adviser. 16.4 Please note that the cover provided under the Contribution Waiver Benefit commences once Discovery has received the first contribution and has accepted the risk. 17. General terms and conditions for the Retirement PayBack Booster, the Ill-Health Income Booster and the Life Plan Optimiser ( Risk Benefits as defined in the accepted quote) 17.1 The Risk Benefits are underwritten by Discovery Life and are governed by the Long-term Insurance Act. 17.2 The Risk Benefits are only available to natural persons and not other entities such as close corporations, companies or trusts. 17.3 The Risk Benefits depend on the details of an existing Life Plan. 17.4 For full details of the Risk Benefits, please refer to the Life Plan Guide or contact Discovery or the financial adviser. 17.5 The benefits provided for by the Life Plan Optimiser are dependent on the existence of a Discovery Life Plan taken in the name of the annuitant. 17.6 The Life Plan Optimiser benefits will be affected by any reduction made in the Life Fund. 18. Liability 18.1 The Risk Benefits will not commence and no liability whatsoever will attach to Discovery for any obligation under the Risk Benefits until notice of acceptance of the risk has been given and the first contribution for the Risk Benefits has been received. 18.2 No claim will be paid to or in respect of the life assured under the Risk Benefits if the claim arose directly or indirectly from a condition, illness, impairment or disability that existed before the commencement of the Risk Benefits and which the life assured knew of and sought medical treatment or advice for from a recognised medical practitioner. 19. Consent To consider a claim under the Risk Benefits, the life assured irrevocably authorises Discovery to: 19.1 Obtain from any person, including Discovery Health, Discovery Health Medical Scheme and Vitality Healthstyle (Pty) Ltd (including Discovery Card), any information including any private health, wellness and lifestyle medical information including HIV status of the life assured which Discovery deems necessary. 19.2 Share with other assurers that information and any other information relating to the life assured contained in this application form or in any related policy or investment contract. This authority cannot be cancelled and endures after death of the life assured. Page 5 of 8

4. Statutory disclosure and terms and conditions (continued) 20. Discovery may refuse to pay a claim If Discovery is unable to obtain sufficient information in order to consider a claim under the Risk Benefits then such claim will not be paid. Discovery may refuse to pay claims under the Risk Benefits if the death of the life assured is due to suicide. 21. Discovery may cancel the Risk Benefits Discovery may cancel the benefit if: 21.1 A fraudulent claim is submitted 21.2 Fraudulent means or devices are used to make a claim 21.3 False information is provided to obtain a benefit 21.4 If the claimant knowingly allows someone acting on their behalf to provide false information in order to obtain a benefit 21.5 The life assured deliberately and wilfully conspires to cause illness or disability that gives rise to a claim. 22. Cession The Risk Benefits may not be ceded or made over or assigned to any person. 23. Unclaimed benefits It is your responsibility to keep your contact information up to date. If a benefit is unpaid because Discovery Life cannot contact you, your beneficiaries or dependants using your contact details, we are required to contact a tracing company to trace you, your beneficiaries or dependants after a prescribed period. You confirm that when you provide Discovery with personal information about any dependant or beneficiary in respect of this policy, they have given you permission to disclose that information to Discovery. This includes their permission to share their personal information with a tracing agent in order for them to help us trace you, your dependants or your beneficiaries. Please note that the tracing fees will be deducted from the unclaimed benefit payout. This is subject to change over the policy term, and will be communicated to you. We will only use the tracing company once to try to trace you. If an external tracing company traces you and we make contact with you, but there is outstanding information, we will keep the benefits in an account for an indefinite period. 24. Fair Collection Notice 24.1 This Fair Collection Notice ( Notice ) explains how we obtain, use, disclose and otherwise process personal information, which may include health and financial information ( personal information ), as required by the Protection of Personal Information Act ( POPIA ). 24.2 Acceptance of these terms and conditions is voluntary, but is a requirement for activation and servicing of your policy. If you do not accept these terms and conditions, we cannot activate and service your policy. 24.3 Discovery Invest ( we or us ) will keep any information, including personal information relating to yourself and your dependants and/or beneficiaries, supplied to us in this application or collected from other sources ( your personal information ) confidential. You confirm that when you provide Discovery Invest with your personal information, your dependants and/or beneficiaries have provided you with the appropriate permission to disclose their personal information to Discovery Invest for the purposes set out below and any other related purposes. 24.4 In the event that you are signing this consent form on behalf of a minor (person younger than 18 years old) you confirm that you are a competent person and authorised to provide such consent on their behalf. 24.5 You hereby consent to the collection, collation, processing, storage and disclosure of your personal information for any purpose relating to this product (or use of your Discovery Card if applicable) for the purpose of: 24.5.1 Administering this policy and for the assessment of any claims under this policy 24.5.2 Enabling any entity within the Discovery Group and/or any third party provider or financial services provider or its representative approved by Discovery to advise you of or offer to you any enhanced benefits or new products which become available from time to time which you may become entitled to or qualify for 24.5.3 Providing relevant information, including your personal information, to a contracted third party who requires such information to render a service to you in relation to this policy, provided that such contracted third party agrees to keep the information confidential. 24.6 Please note: 24.6.1 We may amend this notice from time to time. Please check our website periodically to inform yourself of any changes 24.6.2 You have the right to object to the processing of your personal information 24.6.3 If you believe that we have utilised your personal information contrary to applicable law, you will first resolve any concerns with us. If you are not satisfied with such process, you have the right to lodge a complaint with the Information Regulator, once established. 24.7 You confirm that your personal information may be provided to any other entity within the Discovery Group where you or your dependants already have a relationship with, or where you or your dependants have applied for a product or benefit from such entity. This information will be provided for the administration of your or your dependants products or benefits. 24.8 By signing this application form, you authorise Discovery Invest to obtain and share information about your creditworthiness with any credit bureau or credit provider s industry association or other association for an industry in which Discovery Invest operates. This includes information about credit history, financial history, judgments and default history and sharing of information with tracing agents. 24.9 Please contact us if you do not wish to receive any direct telephonic marketing from us. 24.10 You have the right to request a copy of the personal information we hold about you. To do this, simply complete the Data Subject Request form on www.discovery.co.za and specify what information you would like. We will take all reasonable steps to confirm your identity before providing details of your personal information. 24.10.1 Please note that any such data subject request may be subject to a payment of a fee that is legally allowed. 24.10.2 You have the right to contact and ask us to update, correct or delete your personal information. 24.11 You agree that Discovery may transfer your personal information outside the borders of the Republic of South Africa if you provide an email address hosted outside the borders of South Africa. We may also have to transfer your personal information to another country for processing, storage or academic research. We will ensure that anyone we pass your personal information to agrees to treat your information with the same level of protection as we are obliged to do. 24.12 You agree that Discovery may retain your personal information until you request us to destroy it (unless we are obliged by law to retain it, regardless of such request). 24.13 If Discovery Limited becomes involved in a proposed or actual merger, acquisition or any form of sale of some or all its assets, we may use and disclose your personal information to third parties in connection with the evaluation of the transaction. The surviving company, or the acquiring company in the case of a sale of assets, would have access to your personal information, which would continue to be subject to this notice. 24.14 Discovery Invest is required to collect and retain information in terms of the following legislation: 24.14.1 The Financial Advisory and Intermediary Services Act (FAIS) 24.14.2 The Financial Intelligence Act (FICA) 24.14.3 The Long-term Insurance Act (LTIA) 24.14.4 The Pension Funds Act 24.14.5 The Collective Investment Schemes Control Act 24.14.6 Any other relevant information. 24.15 By signing this application form, you authorise Discovery Invest to share information, including personal information, in this application or in any related document with: 24.15.1 Insurers 24.15.2 Industry Registers such as ASISA and ASTUTE 24.15.3 Contracted third parties, such as tracing agents. Page 6 of 8

5. Declarations I, (full names) the investor, hereby declare the following: 5.1 Warranty: 5.1.1 I have read and understood the contents of this application form. 5.1.2 I agree to be bound by the terms and conditions of this application form, the Investment Fact File and the Business Practices Manual, which, read together, make up the investment contract. 5.1.3 I agree that any commission payable in terms of the Long-term Insurance Act and that any fee payable in accordance with the FAIS Act, may be paid from my investment to my appointed financial adviser on my behalf. I further agree to pay from my investment, the fees as charged by Discovery in the amounts and on the basis explained to me by my financial adviser. 5.1.4 I agree that Discovery will, at their discretion, have the option to pay or collect any amount through the Automated Clearing Bureau or electronic funds transfer (EFT), or by direct debit or credit against my bank account by means of a debit order or credit note addressed to my bankers. Any amounts so received by Discovery will be deemed not to have been received by them and no transaction in respect of such application may be made until the amount of the debit order, cheque or EFT payment has been unconditionally credited to Discovery s bank account with its bankers. 5.1.5 I agree that any alterations made to this application form by me or my financial adviser is not binding unless Discovery agrees to accept the alterations. Acceptance will be communicated by the processing of this application form, the receipt of any monies paid to Discovery and the issuing of the Investment Fact File. 5.1.6 I understand that the products may be subject to tax. I acknowledge that if any of the tax laws, tax regulations, SARS practice or other laws governing the products change, this may have an effect on the products and benefits payable to me. Discovery has not given me any tax advice and I undertake to take such advice if I think it necessary. 5.1.7 I understand that I bear any and all risks associated with the investment options chosen, as I have personally selected the investment options into which the investment amounts are to be placed. 5.1.8 I understand that the value of the benefits payable by the products will vary depending on the performance of the investment options. Discovery has made no representations or guarantees to me regarding the performance of the investment options. 5.1.9 I confirm that, to the extent that Discovery is not my appointed financial adviser, Discovery has not advised me to invest in a particular investment option and as such are not responsible for any choices I have made. 5.1.10 I confirm that I made the decision to invest in the products out of my own free will and from advice given to me by my financial adviser. 5.1.11 I confirm that the monies paid into the products are not from the proceeds of crime. 5.1.12 I confirm that Discovery can take instructions from my financial adviser regarding the investments or product, if I have provided the correct mandate. If Discovery acts on any instruction from my financial adviser and it is later found that my financial adviser did not act in terms of the instructions or authority that I gave him/her, I confirm and agree that, unless my financial adviser is an employee of Discovery, Discovery will not be liable for any loss or damage I may have suffered. 5.1.13 Discovery will not be responsible for any failure, malfunction or delay of any networks or electronic or mechanical device or any other form of communication used in the submission, acceptance and processing of applications and/or transactions. Discovery will not be liable to make good or compensate me or any third party for any damages (whether direct or consequential), losses, claims or expenses. It is my responsibility to ensure that this application form, any instructions that are part of the application form and subsequent instructions submitted electronically by fax or email to Discovery, have been received by Discovery. I acknowledge that Discovery does not consider a fax confirmation or printed copy of a sent email as proof of receiving the document or instruction. 5.1.14 My spouse confirms that he/she has read and understood the terms and conditions of the application forms and agrees to be bound by them, where applicable. I have acquired the permission of my spouse to nominate the beneficiaries as set out in point 1 of the application form and to transact on our collective assets as required by chapter 3 of the Matrimonial Property Act. My spouse understands the legal consequences of such nomination where applicable. 5.1.15 I warrant that I have disclosed all material information to Discovery for the purpose of the Contribution Waiver Benefit (if applicable). 5.1.16 I understand that if I breach the warranty contained in 15 above, Discovery can declare the Contribution Waiver Benefit issued to me void and I will forfeit any contributions paid in respect of the Contribution Waiver Benefit. 5.1.17 If I have selected the Contribution Waiver Benefit, then: 5.1.17.1 I authorise Discovery to obtain from any person, including Discovery Health, Discovery Vitality Healthstyle (Pty) Ltd and the Discovery Health Medical Scheme any information relating to my health, wellness and lifestyle including my HIV status, which Discovery deems necessary when I apply for insurance, claim and on an ongoing basis. 5.1.17.2 I authorise Discovery to share with such insurers any information in this application form or any related policy or any document either directly or through a database operated by or for insurers as a group, at any time (even after my death). This information can be as detailed, abbreviated or coded as Discovery or the operators of such database may decide from time to time. 5.1.18 I confirm that my financial adviser has fully explained the following aspects of the Discovery Retirement Optimiser to me: 5.1.18.1 How my Life Cover will be capitalised to boost my Retirement Annuity Fund 5.1.18.2 How my Life Cover premiums will be affected during retirement 5.1.18.3 How my Fund value will be determined at the paid-up and/or surrender date 5.2 Invest Aware Regulation 28 I know and understand that if Discovery is ever obliged to withdraw all or a portion of the funds from any of the investment choices I have made in order to comply with a statutory or regulatory requirement, then Discovery will invest such withdrawn funds into the Discovery Money Market Fund until I have informed Discovery of another investment choice. 5.3 Invest Aware Escalator funds (if applicable) The guarantee that the Escalator funds will not fall below 80% of the highest value reached (the guarantee level) is a guarantee provided by Deutsche Bank or BNP, as the case may be, and not Discovery Life Limited. This means that I bear the risk if Deutsche Bank or BNP is unable to meet the guarantee for any reason whatsoever. 5.4 Retirement PayBack Booster I/we instruct and authorise Discovery Invest to withdraw the proportion of the Discovery Life PayBack specified in section 2 from my/our bank account wherein the Discovery Life PayBack will be paid. This withdrawal for the Retirement PayBack Booster benefit will be made as soon as any formalities or requirements imposed by my/our bank, as the case may be, have been fulfilled for the transfer of the PayBack amount to Discovery Invest. I/we understand that if Discovery Invest is unable to collect the PayBack amount within a reasonable period (no longer than one month) for whatsoever reason that I/we will not enjoy the benefits of the Retirement PayBack Booster. I/we also agree to pay banking charges and costs relating to the debit order transaction. 5.5 Quote declaration 1. My financial adviser presented me with a final quote (quote number compulsory). 2. The investment options as reflected on the quote correspond to the information in my application form and I confirm that my financial adviser explained the product fees, commission, benefits and all other information contained in the quotation to me. Page 7 of 8

5. Declarations (continued) To nominate a representative who will be linked to the investment policy, please complete the Authorised representative on behalf of the investor form. Have you attached the form to this application? Yes No The Discovery Business Practices Manual describes the various administration processes and the general administration of your investment. (This is available on www.discovery.co.za) This form needs to be submitted with your Discovery Life Application for Assurance form. Have you attached this form? Yes No Signature of principal life/investor Date Y Y Y Y M M D D 5.6 Financial Adviser FICA declaration I confirm that I have identified the investor mentioned in this application form, as well as the person acting on behalf of the investor (if applicable) and have verified their identities according to the requirements as set out in the Financial Intelligence Act, and any related legislation, regulation or guidelines. I verify that I have seen all original documentation in this regard. I further confirm that I will keep a record of the verification documents as required in terms of the FInancial Intelligence Act and will make copies of these documents and details of the verificatin procedures followed available on request to any party entitled in terms of this Act. Signature of financial adviser Date Y Y Y Y M M D D Dr Pikkie Kok 5.7 Commission-specific details Kode: 1087998009 Commission discount percentage required % Page 8 of 8