HOLLARD LIVING ANNUITY - INVESTMENT APPLICATION 1. Important Information 1.1. The Hollard Living Annuity is underwritten by Hollard Life Assurance Company Limited. 1.2. Hollard Investments is a division of Hollard Life Assurance Company Limited and Hollard Investment Managers. 1.3. A Hollard Living Annuity Investment Quotation must be attached to this Investment Application. This is available from your Financial Advisor or the Hollard Investments Client Service Centre on 0860 202 202. 1.4. You may not transfer benefits from a guaranteed life annuity to the Hollard Living Annuity. 1.5. It is imperative that you familiarise yourself with the Hollard Living Annuity 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. 1.6. This application will only be processed once all investment requirements are met and once monies reflect in the Hollard Life bank account. 1.7. All documents can be sent via email to customercare@hollardinvestments.co.za or faxed to +27(0)11 351 3816. 1.8. The daily cut-off for receipt of instructions is 14h00. 1.9. Any instructions received on a public holiday or over a weekend will be processed at the next available working day. 1.10. If you are requesting a unit transfer please ensure that the: a. Rules of the transferring fund/insurer allows 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. 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 your 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). 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. Investor Details Title: First Name(s): Surname: ID/Passport No.: Date of Birth: dd/mm/yy Residential Address: Complex Name: Street/Farm Name: Suburb/District: City/Town: Postal Address: Unit No.: Street No.: 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: 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: Mobile: Income Tax No: Hollard Living Annuity Investment Application - 110718 Page 1 of 5
4. Person Acting on Behalf of Investor Capacity: Power of Attorney Curatorship Estate Late Executor Court Appointed Guardianship Trustee Please note that 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): ID/Passport No.: ID/Passport No.: Residential Address: Complex Name: Unit No.: Street/Farm Name: 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: Email:* Mobile: Signature of person acting on behalf of Investor: Date: dd/mm/yy 5. Investment Details 5.1. The minimum initial investment is R50, 000. 5.2. Is this a Unit Transfer? Yes 5.3. Investment initiated by means of: New Investment (Upon retirement) Transfer from another administrator (Select only ONE) 5.4. Estimated Initial Investment Amount: R 5.5. Transfer 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 source fund/insurer Policy Number Transfer 1 Transfer 2 Transfer 3 5.6. 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 indicate the Hollard Living Annuity Quotation number. This quote must be attached to this investment application form. Quote Number: LA 6. Annuity Income Details 6.1. The annuity income details provided for on the quote attached to this application form will apply to this instruction. Should different annuity details apply, a new quote will be required. 6.2. This section does not apply to transfers from existing annuities. The percentage that determines your annuity income payment as well as the frequency of your payment will remain the same as the original policy. If you wish to change the percentage or the frequency of your annuity payment, you may do so on your next policy anniversary date. The policy anniversary date will remain the same as the policy anniversary date of the original investment. 6.3. The pre-tax annuity income is subject to a minimum of 2.5 per year and maximum of 17.5 per year. These limits are determined by legislation and are subject to change. 6.4. Annuity Income payments are released on the 20 th of each month. The proceeds may take 48 Hours to reflect in your bank account. 6.5. In order for the annuity income to be released on the 20 th, Hollard Investments must receive an instruction and all supporting documentation by 14h00 on the 10 th of the month. 6.6. Unless an Income and Expense account has been selected above, annuity income payments will be deducted proportionally from all investment portfolios. 6.7. If a tax rate was specified in the quote attached to this application form, please provide Hollard Investments with a tax directive to this effect. The directive is valid for the period stated on it. You may renew this by applying to SARS. In the absence of a valid tax directive, the published prevailing tax tables will apply. Hollard Living Annuity Investment Application - 110718 Page 2 of 5
6.8. Bank Account Details for Annuity Income Payments a. Payments to a third party bank account are not permitted. Payment will only be made to a bank account in your name. b. No payments will be made to offshore bank accounts, credit cards or market linked accounts. Bank Name: Branch Name: Acc. Holder: Acc. Number: Acc. Type: Savings Cheque/Current Transmission Other 7. Beneficiary Nominations 7.1. You may nominate one or more parties to receive a benefit on your death. If no beneficiary is nominated, the proceeds will be payable to your estate. 7.2. You may change the beneficiaries appointed in this application by completing a change of details form. 7.3. In the event of your death, your beneficiaries are allowed the following options: a. To withdraw or transfer the full value of the policy; or b. To continue the policy as the new owner. 7.4. Beneficiary Details First Name/Entity Name Surname Relationship ID Number/Registration Number 8. Reporting and Correspondence Share of Benefits (Total 100) 8.1. 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. 8.2. Do you require all correspondence to be sent to your nominated Financial Services Provider (FSP) in addition to being sent to you? Yes 9. Financial Services Provider (FSP) Details and Declaration Practice Name (FSP): FSP Number: Financial Advisor Name: Financial Advisor 9.1. 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. 9.2. 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 Hollard Living Annuity Investment Application - 110718 Page 3 of 5
10. Declaration and Informed Consent in terms of the Protection of Personal Information Act 4, of 2013 (POPIA) 10.1. 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: a. Processing of this application; b. Processing of any subsequent instructions submitted; c. Communicating with me on matters pertaining to my investment; d. Providing me with, but not limited to quarterly investment statements, annual tax; certificates (where applicable), transaction confirmations, updated policy wording etc. 10.2. 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. 10.3. 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. 10.4. 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. 10.5. 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. 10.6. I acknowledge that I have the right to lodge a complaint to the Information Regulator. 10.7. I acknowledge that I have the right to at any time ask Hollard Life to provide me with: a. the details of any of my Personal Information which Hollard Life holds on my behalf ; and b. the details as to what Hollard Life has done with my Personal Information 10.8. 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. 10.9. Hollard Life may use my Personal Information for the promotion of all other Hollard Investments products. 10.10. I understand the purposes for which my Personal Information is required and for which it will be used. 10.11. 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. 11. Investor Declaration 11.1. I confirm that all the statements contained herein are true and accurate at the time of signing this document. 11.2. I confirm that this Financial Advisor, an authorised representative of the FSP named herein, is my appointed Financial Advisor. 11.3. 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. 11.4. Should I be married in community of property in terms of the Matrimonial Property Act, I declare that, prior to the signature date of this instruction, I have obtained the consent of my spouse to use the monies to facilitate this investment. 11.5. The benefits due in terms of this investment application are represented by a lump sum transfer from another approved fund or insurer, and I hereby authorise and instruct the transferring fund or insurer to pay such amount into the Hollard Living Annuity with immediate effect. 11.6. I declare that the rules of the fund from which the proceeds of my investment have originated, allow the purchase of an annuity in my own name and that the benefits offered in terms of the Hollard Living Annuity coincide with the benefits in terms of the transferring fund. 11.7. I confirm that I have read and understood the Hollard Living Annuity Information document that is available on the Hollard website or from my Financial Advisor. 11.8. I understand that the amount of the annuity income and the annuity payment frequency must be reviewed annually in accordance with the annuity conditions, on the policy anniversary date. 11.9. The annuity income is intended to be payable for life. Hollard Investments reserves the right to vary the income percentage in exceptional circumstances. I understand that the annuity is compulsory, non-commutable and may not be transferred, assigned, reduced, hypothecated or attached by creditors. I also understand that the annuity income and investment returns are not guaranteed and that the annuity income payable will be dependent on the annuity income percentage selected and the investment return of the underlying investment portfolios. 11.10. Ownership of the underlying assets will vest with the insurer and not the Investor. 11.11. I confirm that all the statements contained herein are true and accurate at the time of signing this document. 11.12. I confirm that this Financial Advisor, an authorised representative of the FSP named herein, is my appointed Financial Advisor. 11.13. 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. 11.14. I understand that until Hollard Investments has received all necessary documentation and monies the policy will not commence. 11.15. 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. 11.16. 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 policy and that Hollard Investments has not given me any advice in relation thereto. 11.17. I understand and accept all risks associated with this investment. In addition, I confirm that I have read all relevant documentation associated with this policy. 11.18. I understand that should I wish to convert or transfer an existing living annuity, either from the Hollard Living Annuity to another insurer, or from another insurer to the Hollard Living Annuity, no initial advice fee or initial product administration fee charge will be levied. 11.19. I furthermore confirm that I have signed this declaration of my own free will and I regard it as binding. 11.20. I understand and agree to pay all the charges and investment fees applicable to this policy. Hollard Living Annuity Investment Application - 110718 Page 4 of 5
11.21. I acknowledge that Hollard Investments will levy an annual administration fee on the Investment account according to a weighted average fee scale. Hollard Invetsments reserve the right to amend these fees at its sole discretion. I will receive prior written notice in the event of a change. 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. 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 11.22. 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. 11.23. I hereby agree to the payment of all Financial Advisor Fees and annual administration fees associated with this policy as set out in the signed Investment quotation, attached hereto, and any other documentation in which it is appropriate to declare such fees. Signed at on this day of (Place) (Day) (Month) (Year) Signature: Official Capacity: Hollard Living Annuity Investment Application - 110718 Page 5 of 5