The Cornerstone Solution Single Funeral Plan - Debit order

Tel (012) 685 8300 Fax (012) 685 8315 The Cornerstone Solution Single Funeral Plan - Debit order My name My intermediary My intermediary s telephone number

CORNERSTONE The Cornerstone Solution Single Funeral Plan main policy Debit-order application form Policy number Please make sure that you understand this entire form, as well as the policy provisions provided with it. Complete all pages carefully, making sure that all blocks selected are marked clearly with an X, and then sign the form. We will consider your application according to our underwriting rules and practice. Tell us immediately if any information changes. You and we (Assupol) are the only persons involved in entering into this policy. About you, the policyholder Full first names Title Initials Gender male female ID Tel (work) ( ) Marital status Cell single married divorced widowed Tel (home) ( ) E-mail Street or postal address Postal code About the main life insured, if you are t a life insured Full first names ID Relationship to you Benefits and premiums you may select Mark monthly premium you choose with an X. Single plan 18-64 years Plan A Plan B Plan C Cover Monthly premium R 6 000 R 50 R 12 000 R 85 R 18 000 R 110 Total monthly premium R How the premium will be paid Authorization I will pay by debit order. I will pay from m m y y y y Payment must be made on the day of every month. Account-holder Name of bank Name of branch Branch code Account number Type of account current savings transmission I authorize Assupol to draw the premiums from my bank account. If the premium changes for any reason in terms of the policy, or by agreement between Assupol and the policyholder, the changed premium may likewise be drawn from my bank account. If payment cant be done on the preferred day of the month filled in above, it must be done on a day that is as close as possible to that day, determined by Assupol. If the policy ends, this authorization also ends. I may cancel, amend or replace this authorization by written tice to Assupol. I accept that Assupol must receive the tice t later than 30 days before the month from which the cancellation, amendment or replacement is to apply. The reference on your bank account statement will start with: Assupol. My signature Date d d m m y y y y 1 Cornerstone Solution Single debit-order application form 02 May 2018

Policy number About your beneficiary This is the person you appoint to claim and receive the policy benefits after your death. He or she must be 18 years or older. You may change your beneficiary at any time for example, if you get married or divorced. If for any reason payment cant be made to your beneficiary, we may pay the amount required for the life insured s funeral to the undertaker who handles the funeral or to the person who proves that he or she has paid for the funeral. Any remaining benefits will be paid to your deceased estate. Full first names ID Title Initials Gender male female Relationship to you Analysis of your funeral needs It is important that you have the right and eugh funeral insurance to meet your and your family s needs. To achieve this, it is necessary to analyze your funeral insurance needs. Your intermediary must complete this needs analysis. What are your needs? 1. Do you have funeral insurance? 4. How much is your total monthly premium? R 2. If, how many funeral policies do you have? 5. Do you need funeral cover? 3. How much is your total funeral cover? R 6. Do you want to add lives insured? Why will the product you are applying for meet your needs? 1. You and your dependents will have funeral cover? 2. Your funeral cover will increase to the amount you need? 3. Other reasons? Declaration by you, the policyholder I declare that all information in this form is complete and correct, and that I received a signed copy. I am satisfied that I understand everything I need to kw about the policy and my funeral needs analysis above, and that I will be able to pay the premiums. I understand that if information is t correct, benefits under the policy may be declined and premiums paid could be forfeited. Are you taking out this policy to replace any of your existing insurance policies? Companies in the Assupol group of companies may from time to time offer other products or services to me. My signature Date d d m m y y y y Declaration by the intermediary who assists with this application Province Code Initials I have checked that this form has been properly completed and signed. I discussed it, and the policy provisions provided with it, with the policyholder. I have t given, and will t give, money or anything of value to the policyholder or a life insured as an inducement to take out this policy. I explained to the policyholder the implications of replacing insurance. I informed the policyholder that, for services rendered in respect of this application and the policy, Assupol pays to Cornerstone a once-off commission equal to the first month s premium, and a recurring commission equal to 24,5% of every monthly premium. Intermediary s signature Date d d m m y y y y 2 Cornerstone Solution Single debit-order application form 02 May 2018

Policy provisions Your policy, and our contractual commitment, takes effect when we (Assupol) accept your application for the policy. Your application form and these policy provisions are the complete and only record of your policy, and also the summary of your policy required by section 48 of the Longterm Insurance Act. Life insured This is a person whose life is insured under your policy. This is you, or the main life insured. You must have an insurable interest in the main life insured. You have, for example, such an interest in your spouse, children, parents and other family members. Main life insured This is the person whose life you insure under your policy, if your life is t insured under the policy. When cover and waiting periods start For every life insured death cover for an accidental death starts, and the waiting period for death cover for natural (n-accidental) death and suicide starts, on the first day of the month in which the first monthly premium for cover for that life insured is due. The waiting period for natural death is six months. For suicide it is 24 months. During a waiting period premiums must be paid, but benefits are t provided. Accidental death is death caused by an incident that causes harm to the body of the life insured from outside the life insured, which harm excludes any sickness and which incident and harm the life insured did t intend and reasonably could t have foreseen. The incident must be the direct and only cause of death, and death must happen within 30 days after the incident. Age of life insured when cover starts You, and the main life insured, must be under age 65. Maximum funeral cover for one person When a person takes out funeral insurance with us, the total funeral cover for that person under all individual and group policies with us may t be more than a maximum of R50 000. Any cover above the maximum automatically falls away. About your premiums The premium for your policy is payable monthly, before the end of every month. The premium we receive in a particular month provides cover for that month. The premium pays for death cover only, and t for any investment or cash value. Premiums are t refunded if your policy ends for any reason. If two monthly premiums in a row are t paid, and both are t paid by the end of the month in which the second premium should have been paid, your policy ends automatically. If within 12 months of your policy ending, we again receive a premium, we may reinstate your policy, and new waiting periods will then apply. If premiums are t paid in full, benefits also cant be paid in full. Only a percentage of the benefit can then be paid namely a percentage that is the same as the percentage of premiums paid. For example, if you had to pay premiums of R1 000, but paid only R500, it means you paid only 50% of the premiums. Therefore, only 50% of the benefits can then be paid. So, if the benefit amount is R10 000, only R5 000 can be paid. When policy benefits will t be paid A benefit will t be paid if information (for example, about your relationship with lives insured or the age of lives insured), was t provided to us before the start of the benefit in question, or is t correct. A benefit will also t be paid if the life insured s death is caused or accelerated directly or indirectly by war, civil commotion or terrorist activity, or if the life insured dies while committing a criminal activity. You can cancel your policy You can cancel your policy at any time by written tice to us. If we receive your tice within 30 days after you have received these policy provisions, your policy ends when we receive your tice. This is kwn as a cooling-off cancellation. If we receive your tice after the 30 days, your policy will end at the end of the month in which we receive your tice, and then premiums received after the policy has ended will be refunded. The actuarial basis of your policy The Cornerstone Solution Single Funeral Plan Your policy operates according to actuarial rules, specifications and formulae, which are approved according to law, and which are kwn as the actuarial basis of your policy. This ensures that your policy is financially sound, and is carried out properly and fairly.

Policy provisions continued The Cornerstone Solution Single Funeral Plan Information about you We and Cornerstone may use information about you, also personal information meant in the Protection of Personal Information Act, that we lawfully obtained in the past or may obtain in future, including the information provided for your application for this policy, for the following purposes: to consider applications for insurance of which you are the policyholder or a life insured; and for all purposes of such insurance, issued in the past or in future, particularly to consider claims for benefits and to trace persons who could receive benefits. We may for these purposes, at any time, also after your death: obtain such information from other persons and entities, particularly from other insurers and registered credit bureaus, and you authorize them to give such information to us; share such information with other insurers directly or through a data base that insurers operate as a group, and in such form as we or the operators of the data base may decide. How to claim a policy benefit Visit any of our offices, set out on the back of this folder, or phone 0861 235 664. Our offices are also open on Saturdays from 08:00 to 13:00. We must receive a completed claim form within six months, after the death of the life insured. The persons who claims must, at their own cost, prove the claim, show that exclusions apply, and give us all information and documents we need to consider the claim. This must include: the claim form completed and signed as required certified copy of the valid ID document of the person who claims certified copy of the original death certificate of the life insured form DHA 5 certified copy of the valid ID document of the life insured, with deceased or a similar tice stamped on it copy of the tification/registration-of-death form DHA1663 copy of a valid bank statement of the person who claims, t older than three months, showing the account-holder and the account number police report if the death is due to unnatural causes for example, a motor-vehicle accident other documents that we may reasonably require. For other assistance Visit any of our offices, or contact our client services department: tel 0861 235 664 e-mail clientservices@assupol.co.za fax 0861 329 287 post PO Box 35900, Menlo Park, Pretoria, 0102 Complaints Our commitment is to provide excellent service to you. If, after having contacted one of our offices or our client-services department, you are still t satisfied, please contact our complaints department: tel 087 098 0290 e-mail complaints@assupol.co.za fax 087 230 5669 post PO Box 35900, Menlo Park, Pretoria, 0102 If, after you have contacted our complaints department, you are still t satisfied, you could approach the: Ombudsman for long-term insurance about an aspect of your policy fax 021 674 0951 e-mail info@ombud.co.za post Private Bag X45, Claremont, 7735 Fais Ombud about the conduct of the intermediary who assisted you fax 012 348 3447 e-mail info@faisombud.co.za post PO Box 74571, Lynnwood Ridge, Pretoria, 0040 Underwritten by Assupol Life Ltd Reg 2010/025083/06 Authorized financial services provider www.assupol.co.za Summit Place Office Park, Building 6, 221 Garsfontein road, Menlyn, Pretoria, 0181 PO Box 35900, Menlo Park, Pretoria, 0102 Compliance department: fax 087 230 5667 e-mail compliance@assupol.co.za

Assupol and Cornerstone branches Bergville Bergville Central Arcade Shop 8 4 Broadway street Bergville 3350 Bethlehem Shop 1 36B Roux street Bethlehem 9701 Bloemfontein Dia House 148 Zastron street Bloemfontein 9300 Bochum Stand 526 Extension 3 Senwabarwane Bochum 0790 Burgersfort 133 Morone Shopping Centre Shop 38B Kastania street Burgersfort 1150 Bushbuckridge Eagles Business Centre Shop 106 Stand 4 R40 road Bushbuckridge 1280 Cape Town 5th St Georges Mall Building Shop 8 20 Adderley street Cape Town 8000 De Aar Novel Building 23 Main street De Aar 7000 Durban Redefine Towers Shop 105-110 320 Dr Pixsley Kaseme street Durban 4001 East London 91 Western avenue Vincent East London 5217 Eerstehoek Pholani Tarven Stand 11 & 12B Enhlazathe 5 Elukwatini 1192 Emanguzi Lykouria Investments Complex Shop 3A Gelegele road Ekuthukuzeni area Manguzi/Kwangwanase 3973 Empangeni 1 Pearce road Empangeni 3880 Ermelo KWB Building Office 8 22 De Clerq street Ermelo 2351 Escourt Slades Arcade Shop 6A 127 Albert street Estcourt 3310 Eshowe Four Square Building Shop 8B Osbourne road Eshowe 3815 Giyani Masingita Shopping Centre Shop 11 cnr Malamulele & Main road Giyani 0826 Greytown New March Building 151 Pine street Greytown 3250 Groblersdal Medical Centre 14 Kruger street Groblersdal 0470 Jane Furse Stand 28 Welgelegen Schoord road Jane Furse 1085 Johannesburg Newtown Junction Mall Shop 161 100 Carr street Newtown Johannesburg 2000 Ixopo Shop 5 25 Margaret street Ixopo 3276 Kamhlushwa SDK Catering & Confectionery Stand 1642 Kamhlushwa 1332 Kempton Park Festival Mall Shop 34 cnr CR Swart drive & Kelvin street Esther Park Kempton Park 1619 Kimberley Chapwood Chambers 15-17 Chapel street Kimberley 8301 King William s Town Market Square Shop 8A Maclean street King William s Town 5600 Klerksdorp West End Centre Office 29A 51 Leask street Klerksdorp 2571 Kokstad 76 Hope street Kokstad 4700 Kroonstad 41 Buitekant street Kroonstad 9499 Kuruman 7A Steward street Kuruman 8460 Kwaggafontein Site 25 Section C 26 Mkobola street Empumalanga Kwaggafontein 0458 Ladysmith Christopher Arcade Shop 4 133 Merchison street Ladysmith 3370 Lephalale Carbo Building Shop 6 3 Kort street Lephalale 0555 Lusikisiki Lusikisiki Plaza Shop 25 & 26 Lusikisiki 4820 Mabopane Central House Suite 204 2nd floor Access road Mabopane 0190 Mahikeng Shasons Centre Office 7 46 Shippard street Mahikeng 2745 Marapiyane Molai Shopping Centre Shop 13 Stand 2823 Neu Halle Marapiyane 0431 Mbombela Nelcity Centre Shop U6 & U7 cnr Paul Kruger & Samora Machel drive Mbombela 1200 Melmoth Elsabas Centre Shop 14 Symmonds street Melmoth 3835 Middelburg Steve Dickenson Building 22 Bhimay Dimane street Middelburg 1055 Mitchell s Plain Liberty Promenade Shopping Centre Shop C04 AZ Berman drive Mitchell s Plain 7785 Mkuze Mkuze Station Shopping Centre Shop 6 Falcon street Mkuze 3965 Modimolle 105 Albert Luthuli street Modimolle 0510 Mogwase JR Centre Room 2 & 3 Stand 965 Unit 3 JR Building Shopping Complex road Mogwase 0314 Mokopane 42 van Riebeek street Mokopane 0601 Mthatha Shop 60, 62 & 64 BT Ngebs City Mall Mthatha 5100 Mtubatuba Oriole Centre Unit 3G 30 Jan Smuts avenue Mtubatuba 3935 Newcastle 50 Sutherland street Newcastle 2940 Nkandla KFC Building Room 4 Ndlangubo street Nkandla 3855 Nongoma Nongoma Medical Centre Shop 2 1 Main road Nongoma 3850 Nqutu Nqutu Abenguni Building Lot 57 Mdlalose street Nquthu 3935 Phalaborwa FCM Building Office 8B 20 Wildevy avenue Phalaborwa 1390 Phuthaditjhaba Naledi Mall Office 102K Phuthaditjhaba 9866 Pietermaritzburg 221 Pietermaritz street Pietermaritzburg 3201 Piet Retief Bohmer Centre Office 19 cnr Mark & De Wet street Piet Retief 2380 Pinetown Charter House 2nd floor Suite 204 75 Crompton street Pinetown 3600 Polokwane 28C Schoeman street Polokwane 0699 Pongola 223 Klasie Havenga street Pongola 3170 Port Elizabeth 223 Cape road Mill Park Port Elizabeth 6001 Port Shepstone Cowrie Court Shop 1 Nelson Mandela drive Port Shepstone 4240 Potchefstroom 84B Walter Sisulu street Potchefstroom 2531 Pretoria City Centre Tomkor Building Shop 5 101 Du Toit street Pretoria 0001 Queenstown 46 Cathcart road Queenstown 5319 Rustenburg 31 Steen street Rustenburg 0299 Soshanguve Shop 102 Richard Thorntree Shopping Centre cnr Hebron road & Umphafa road Soshanguve - VV Township 0164 Soweto Maponya Mall Shop 341 2127 Chris Hani road Klipspruit extension 5 Soweto 1809 Standerton The Pillars Building 14A Mbonani Mayisela street Standerton 2430 Stanger 54 Chief Albert Luthuli street Stanger 4450 Taung Taung Forum Building Office 01/01D Station road Taung 8584 Thohoyandou LimDev Building Office 79 & 81 Block C Post Office street Thohoyandou 0950 Tzaneen CRS Mall Shop 1 32 Skirving street Tzaneen 0850 Ulundi Shop 19 30 Princess Magogo street Ulundi 3838 Umzinto Archibald Building Shop 3 Ixopo road Umzinto 4200 Upington 33 Schroder street Upington 8801 Vereeniging Markpark Shopping Centre Shop S2A cnr Voortrekker street Beaconsfield avenue Vereeniging 1930 Vryheid Empire Building Office 1 118 Hoog street Vryheid 3100 Vryburg Du Plessis Sentrum Shop 7 Stand 2137 24 De Kok street Vryburg 8601 Welkom 147 Investment CC Building Shop 3 324D Stateway street Welkom 9459 Worcester Quenet s Arcade Shop 11 72 High street Worcester 6850 Zeerust LTR Building 48 Church street Zeerust 2865 Head Office Summit Place Office Park Building 6 221 Garstfontein road Menlyn Pretoria 0181