HOLLARD RETIREMENT ANNUITY PLAN APPLICATION FORM 1. Important Information 1.1. Please complete this application form if you would like to become a Member of the Hollard Retirement Annuity Fund. 1.2. Hollard Investments is a division of Hollard Life Assurance Company Limited and Hollard Investment Managers. 1.3. This application will only be processed when all investment requirements are met, once monies reflect in the Hollard Retirement Annuity bank account and subject to the relevant Rules of the Fund and applicable legislation. 1.4. It is imperative that you familiarise yourself with the Hollard Retirement Annuity Plan Information Document. This is available from your Financial Services Provider, the Hollard Investments Client Service Centre or on our web site at www.hollard.co.za. 1.5. All documents can be sent via email to customercare@hollardinvestments.co.za or faxed to +27(0)11 351 3816. 1.6. The daily cut-off for receipt of instructions is 14h00. 1.7. If you are requesting a unit transfer please ensure that: a. The Rules of the transferring Fund allow for this. b. The underlying investment portfolios you select and their class are available at the time of the transfer. If not, you must switch into an available investment portfolio and class before the transfer is completed. Please arrange this with your current Fund prior to the transfer. 1.8. Any instructions received on a public holiday or over a weekend will be processed on the next available working day. 2. Document Checklist Please ensure to include all of the below documents in your Investment Application: Completed investment application form. A signed Investment Quotation For a model portfolio investment, a completed Hollard Investment Managers Client Mandate must be provided. The Client Mandate is available from your Financial Advisor. Certified copy of South African green bar-coded ID/new smart card ID or valid passport, with visible photograph and legible text. Proof of banking details (cancelled cheque or bank statement, not older than 3 months). Proof of deposit of funds/transfer to the Hollard Retirement Annuity Fund bank account. Confirmation of income tax number. For a transfer, a recent statement of your investment from the transferring administrator. If you have a person acting on your behalf, the following must be supplied for such a person: Proof of authority to act. Certified copy of South African green bar-coded ID/new smart card ID or valid passport, with visible photograph and legible text. 3. Member Details Title: Surname: First Name(s): ID/Passport No: Date of Birth: dd/mm/yy Complex Name: Street/Farm Name: Unit No.: Street No.: Suburb/District: City/Town: Postal Address: Postal address is as per the residential address: Yes No if no, please complete a postal address below. Address Type: PO Box Private Bag Postnet Suit Box/Bag/Suite Number: Post Office Name: Hollard Retirement Annuity Fund 12/8/38099 Application Form - 010517 Page 1 of 6
Contact Details: Home: Mobile: Email:* * Unless specifically instructed, Hollard Investments will send all investment statements via email. Refer to the section on Reporting and Correspondence. Marital Status Married Divorced Never married Other (please specify) Country of Residence: Income Tax No: 4. Person Acting on Behalf of Member Capacity: Power of Attorney Curatorship Estate Late Executor Court Appointed Guardianship Trustee Please note that certified proof of the capacity stated above will be required on the submission of this application, without which it will not be processed. Title: Surname: First Name(s): Date of Birth: dd/mm/yy ID/Passport No: Complex Name: Street/Farm Name: Unit No.: Street No.: Suburb/District: City/Town: Postal Address: Postal address is as per the residential address: Yes No if no, please complete a postal address below. Address Type: PO Box Private Bag Postnet Suit Box/Bag/Suite Number: Post Office Name: Contact Details: Home: Mobile: Email: Signature of person acting on behalf of Investor: Date: dd/mm/yy 5. Investment Details 5.1. The minimum once-off investment amount or transfer amount is R50, 000. The minimum recurring debit order amount is R500 per month. 5.2. Please note, debit orders are restricted to R1 000 000 per debit. 5.3. Investment Method: a. Once-off Investment Investment Amount: R b. Recurring Debit Order Debit Order Amount: R c. Transfer Estimated Transfer Amount: R Is this a Unit Transfer? Transfer initiated by means of: Yes A transfer from a Retirement Annuity Fund or Preservation Fund A transfer due to pension interest in a divorce order A transfer from an Employer Fund Last date of employment: dd/mm/yy 5.4. Transferring Fund Details In the event of multiple transfers, amounts will be invested as and when they are received by the Administrator, provided all requirements have been met. Registered name of Fund Member Number Transfer 1 Transfer 2 Transfer 3 Hollard Retirement Annuity Fund 12/8/38099 Application Form - 010517 Page 2 of 6
5.5. Investment Allocation a. Please see the latest portfolio list to confirm your selection of investment portfolios. The portfolio list is available on our website at www.hollard.co.za. b. Please provide the Investment Quotation number. This quote must be attached to this investment application form. Quote Number: RA c. Regulation 28 of the Pension Funds Act 24 of 1956, as amended, specifies maximum limits with regards to the different asset classes that a Retirement Annuity Fund investment may be exposed to. The investment portfolios which have been made available for selection within the Hollard Retirement Annuity Plan comply with these limits. d. Phase-in Election: You may elect to gradually invest into your selected investment portfolios from the Hollard Prime Money Market Fund by means of a fixed instalment phase-in over a 3, 6, 9 or 12 month period. This option is only available for your initial investment and not for additional investments, and is not available if you are investing in a model portfolio. The phase-in instruction is processed on the 15 th day of each month over the preferred term selected. Should the 15 th fall on a weekend or public holiday, the phase-in will be processed on the first working day thereafter. e. Do you require a phase-in? Yes If Yes, please select the term below by ticking one option. Phase-in Term: 3 months 6 months 9 months 12 months 6. Payment Details for Once-off Investments 6.1. Once-off debit requests cannot be accommodated. 6.2. No cash deposits will be accepted. 6.3. Cheque deposits, electronic transfers and internet transfers should be made to the bank account below. 6.4. If Hollard Investments does not receive a completed application form and required documentation within 10 days from the date the monies are received by the Fund, Hollard Investments will return the deposited monies to the source bank account. 6.5. Please use your identity number as a payment reference to assist in the timeous processing of this instruction. Hollard Retirement Annuity Fund Banking Details: Bank Name: Standard Bank Branch 00 0205 Acc. Holder: Hollard Retirement Annuity Fund Branch Name: Johannesburg Acc. Type: Business Current Account Acc. Number: 000 354 724 7. Recurring Debit Order Details Hollard Investments must receive this instruction 5 days prior to the debit order date. Please supply proof of bank account details for the bank account provided. Please debit my account on the: 1st OR 20th of the month, commencing on the dd/mm/yy Banking Details: Bank Name: Branch Name: Acc. Holder: Acc. Number: Acc. Type: Transmission Cheque/Current Savings Other: The bank account holder hereby authorises the Hollard Retirement Annuity Fund to draw direct debits against the bank account detailed above. Signature of Bank Account Holder: 8. Details of Dependents 8.1. Dependants are a special category of persons as described in the Pension Funds Act 24 of 1956, as amended, and are person s dependant on you for financial support, along with your spouse and children. They are given preference when allocating benefits. 8.2. Should you have more than six dependants, please copy this page and provide the additional dependant details on the additional page, and attach it when submitting your request. 8.3. Dependant Details a. Name Surname Date of Birth Relationship b. Name Surname Date of Birth Relationship Hollard Retirement Annuity Fund 12/8/38099 Application Form - 010517 Page 3 of 6
c. Name Surname Date of Birth Relationship d. Name Surname Date of Birth Relationship e. Name Surname Date of Birth Relationship f. Name Surname Date of Birth Relationship 9. Beneficiary Nominations 9.1. You can nominate beneficiaries that the Fund should consider to receive the benefit on your death. 9.2. The allocation of the benefits at your death is at the discretion of the Trustees of the relevant Fund and is subject to section 37C of the Pension Funds Act 24 of 1956, as amended. The beneficiaries you nominate may therefore not be allocated a benefit by the Trustees on your death. 9.3. Please attach a letter of explanation to this application form if there are any special factors that you would like the Trustees of the Fund to take into account. 9.4. Should you have more than six beneficiaries, please copy this page and provide the additional beneficiary details on the additional page, and attach it when submitting your request. 9.5. Beneficiary Details First Name Surname Relationship ID Number 10. Reporting and Correspondence Share of Benefits (Total 100) 10.1. It is your responsibility to ensure that the details for reporting and correspondence held by Hollard Investments are current and accurate. Hollard Investments will not be held liable for communications of any nature not being received by you, or any circumstances that may arise as a result of such non-receipt. 10.2. Do you require all correspondence to be sent to your nominated Financial Services Provider (FSP) in addition to being sent to you? Yes 11. Fund Details FUND NAME REGISTRATION NUMBER Hollard Retirement Annuity Fund 12/8/38099 Hollard Retirement Annuity Fund 12/8/38099 Application Form - 010517 Page 4 of 6
12. Financial Services Provider Details (FSP) and Declaration Practice Name (FSP): Financial Advisor Name: FSP Number: Financial Advisor 12.1. FAIS Declaration: a. I declare that I am a licensed FSP and have made the disclosures required in terms of the Financial Advisory and Intermediary Services Act, No. 37 of 2002 and subordinate legislation thereto, to the Investor. b. I, the appointed FSP named herein, hereby declare that I have fully explained to the Investor named herein, the details and constraints of the investment in question and have received confirmation from them of their understanding thereof, that Hollard Investments has the right to review this investment application if at any time they feel the Investor does not understand the implications of their decision and the associated consequences. c. Further, I warrant that I have explained all fees that relate to this investment to the Investor and I understand and accept that the Investor may withdraw his/her authority for payment to me in writing to Hollard Investments. 12.2. Investor Fee and Discretionary Mandate Declaration a. I confirm that I have entered into a mandate with the FSP named herein, who is an approved discretionary FSP and I have attached a signed copy of the mandate to this instruction. Yes b. I confirm my understanding that if I have not selected Yes, only transaction instructions received from, and signed by me, will be acted upon. c. I further confirm my understanding of the fact that if I have selected Yes, Hollard Investments will act on all transaction instructions received from the nominated FSP irrespective of whether or not authorisation for the transaction in question is received from me. d. I indemnify Hollard Investments against any losses whatsoever that may occur as a result of transaction instructions carried out, where such instructions are signed and submitted to Hollard Investments by the FSP without my knowledge. e. I confirm that the Investor named herein and I have agreed to the payment of the specified Financial Advisor Initial Fee and Financial Advisor Annual Fee, as specified in the investment quotation (If a fee was not specified in the quote, a zero initial and annual fee will be applied). f. I furthermore confirm that I have signed this declaration of my own free will and I regard it as binding. Financial Advisor Signature: Date: dd/mm/yy Investor Signature: Date: dd/mm/yy 13. Declaration and Informed Consent in terms of the Protection of Personal Information Act 4, of 2013 (POPIA) 13.1. I hereby voluntary consent to Hollard Life processing my Personal Information, including but not limited to the actions listed below, for the purpose of administrative functions in terms of this contract: 13.1.1. Processing of this application; 13.1.2. Processing of any subsequent instructions submitted; 13.1.3. Communicating with me on matters pertaining to my investment; 13.1.4. Providing me with, but not limited to quarterly investment statements, annual tax; certificates (where applicable), transaction confirmations, updated policy wording etc. 13.2. I expressly and voluntary consent to Hollard Life disclosing and transferring my Personal Information to Hollard Life contracted administrators for administrative and/ or servicing purposes in connection with this contract. 13.3. I further consent to the processing of my personal information by way of trans-bordering flow of information where applicable. This will occur where my Personal Information has to be sent to offshore service providers for purposes of outsourcing in connection with the administration and / or servicing of this contract. 13.4. Where my Personal Information is transferred outside the borders of the Republic of South Africa, such is done only to countries that have similar privacy laws to that of the Republic of South Africa or where such facilities are bound contractually to no lesser than those imposed by POPIA. 13.5. I acknowledge that in terms of Section 11 (3) of POPIA that I have the right to object, at any time, to the processing of my Personal Information in the prescribed manner, on reasonable grounds relating to my particular situation, unless legislation provides for such processing. On receipt of an objection Hollard Life will put a hold on any further processing of my Personal Information until the objection has been resolved. 13.6. I acknowledge that I have the right to lodge a complaint to the Information Regulator. 13.7. I acknowledge that I have the right to at any time ask Hollard Life to provide me with: 13.7.1. the details of any of my Personal Information which Hollard Life holds on my behalf ; and 13.7.2. the details as to what Hollard Life has done with my Personal Information 13.8. POPIA requires that all of my Personal Information supplied must be complete accurate and up to date. Whilst Hollard Life will use its best endeavours to ensure that my Personal Information is reliable, I acknowledge that it will be my responsibility to advise Hollard Life of any changes to my Personal Information as and when this may occur. 13.9. Hollard Life may use my Personal Information for the promotion of all other Hollard Investments products. 13.10. I understand the purposes for which my Personal Information is required and for which it will be used. 13.11. I give Hollard permission to process my Personal Information as provided above. Signed at on this day of (Place) (Day) (Month) (Year) Signature *: Official Capacity: * If the applicant is under the age of 18, this signature must be that of the Person Acting on Behalf of the Policyholder. Hollard Retirement Annuity Fund 12/8/38099 Application Form - 010517 Page 5 of 6
14. Member Declaration 14.1. I confirm that all the statements contained herein are true and accurate at the time of signing this document. 14.2. I confirm that this Financial Advisor, as authorised representative of the FSP named herein, is my appointed Financial Advisor. 14.3. I accept and bind myself to the terms and conditions of the registered rules of the selected Retirement Annuity Fund as well as any conditions the Trustees may formulate thereunder. 14.4. I confirm that the residential address provided will be the Domicilium Citandi et Executandi, all letters and notices served on this address will be deemed to have been received by me, and accept that I am responsible for updating this address to ensure I receive all notifications as and when they are issued by Hollard Investments or the administrator. I may change my residential address by providing written notice to Hollard Investments. 14.5. I confirm that I have read and understood the Hollard Retirement Annuity Plan Information Document that is available on the Hollard website or from my Financial Advisor. 14.6. Ownership of the underlying assets will vest with the Fund and not the Member. 14.7. I understand that I may not withdraw from the Fund prior to my retirement, other than in the circumstances as conveyed in the relevant Information document. Any benefits will only be payable on retirement, death or disability in terms of the Rules of the Fund and I confirm that I understand these conditions. 14.8. I understand that should I wish to convert or transfer an existing retirement annuity from or to another Retirement Annuity Fund, no initial advice fee or initial product administration fee will be levied. 14.9. I understand that this membership application and all the information contained herein shall form part of my contract in terms of the Fund and is in compliance with the Hollard Retirement Annuity Fund Rules. 14.10. I understand and accept all risks associated with this investment. In addition, I confirm that I have read all relevant documentation associated with this investment. 14.11. If the benefits due in terms of this investment application are represented by a lump sum transfer from another approved Fund, I hereby authorise and instruct the transferring Fund to pay such amount to the Hollard Retirement Annuity Fund with immediate effect. 14.12. I understand and acknowledge that due to the nature of this investment there is no cooling off period. 14.13. I acknowledge and agree that all facsimile/electronic representation of all documents, including this application form, and any other instructions hereafter, including mandates, consents, commitments and the like, which purport to emanate from me, shall be deemed to have been given by me in the form actually received by Hollard Investments. I hereby waive all rights I may have or may obtain against Hollard Investments arising directly or indirectly from any losses or damages that I may suffer because Hollard Investments acted on any purported facsimile/electronic representation, and I indemnify Hollard Investments against any claims, demands or actions suffered by them because they acted on a facsimile/electronic representation. 14.14. I understand that until Hollard Investments has received all necessary documentation and monies, the investment will not commence. 14.15. I understand that Hollard Investments will not be held responsible for any delays in processing as a result of the delays caused by, or initiated by the Managers of the underlying investment portfolios. 14.16. I understand that I am solely responsible (in consultation with my Financial Advisor(s)) for the selection of the investment portfolios to be held within the investment and that Hollard Investments has not given me any advice in relation thereto. 14.17. I have satisfied myself that under any taxation or assurance legislation to which I may be subject, I am permitted to effect the investment. 14.18. I understand and agree to pay all the charges and investment fees applicable to this investment. 14.19. The Managers of the underlying investment portfolios will levy an annual portfolio management fee and initial management fee (if applicable). The full list of investment portfolio management fees are available on the portfolio list which can be found on the Hollard website www.hollard.co.za. 14.20. I acknowledge that Hollard Investments will levy an annual administration fee on the Investment account according to a weighted average fee scale. These fees may differ in certain circumstances. I further acknowledge that I have reviewed the signed investment quotation applicable to this investment which disclose the fees applicable to my investment. Hollard Investments reserve the right to amend these fees at its sole discretion. I will receive prior written notice in the event of a change. Investment Value Annual Admin Fee (Ex VAT) From R0.0 to R1 million 0.45 Next R500 000 0.40 Next R500 000 0.35 Thereafter 0.25 Signed at on this day of (Place) (Day) (Month) (Year) Signature: Official Capacity: Hollard Retirement Annuity Fund 12/8/38099 Application Form - 010517 Page 6 of 6