OLD MUTUAL UNIT TRUSTS LIVING ANNUITY

OLD MUTUAL UNIT TRUSTS LIVING ANNUITY IMPORTANT INFORMATION 1. Please complete all the relevant sections and sign section 14. Investors in Shari ah-compliant unit trusts must sign section 7 as well. 2. The completed form and a certified copy of your identity document/passport can be scanned and emailed to uttransactions@oldmutual.com, faxed to +27 (0) 21 509 7117 or handed in at any Old Mutual branch. Illegible and incomplete forms may lead to delays. Contact our service centre at 0860 234 234 if you have any queries. 3. Please note a quote must be submitted with this form for new business only. If you do not have access to a quotes package, please contact our service centre who will provide you with a quote. 4. Your investment will be made once we have received the completed form and supporting documents and your funds reflect in the correct bank account. 5. Once your account has been opened, you can register via www.omut.co.za to view and/or transact on your portfolio. 6. It is important to provide a cellphone number, as transaction notifications are only sent via SMS. PROCESSING TIMES If all the requirements are met by 15h00 (13h00 for all transactions involving money market funds) you will receive the same day s price. Else the first working day s price will apply once all requirements have been met, with the same cut-off times applying. ABOUT THE OLD MUTUAL UNIT TRUSTS LIVING ANNUITY The Old Mutual Unit Trusts Living Annuity is designed to provide retirees with a regular income from their accumulated retirement savings. You can select an annual income percentage of between 2.5% and 17.5% (of the portfolio value on the anniversary date), which can be adjusted annually. Your portfolio can be structured to suit your risk profile and investment preferences from any of the available unit trust funds (subject to restrictions on unit trust availability that may apply from time to time). Performance is dependent on the unit trust/s chosen and there is no guaranteed income level. Your income can therefore decrease or increase in line with the performance of your underlying portfolio. All risks associated with this investment are therefore carried in full by the annuitant. Any capital that is not exhausted can be bequeathed to your selected beneficiaries. This is a member-owned annuity, and investment into this annuity can only take place if the rules of the transferring fund allow such investment. Please read the Old Mutual Unit Trusts Living Annuity fact sheet to ensure you understand the product. PROCESSING TIMES If all the requirements are met by 15h00 (13h00 for all transactions involving money market unit trusts) you will receive the same day s price. Else the first working day s price will apply once all requirements have been met, with the same cut-off times applying. Please complete this form using block letters and tick ( ) where appropriate. PROPOSAL TO BUY UNITS In my capacity as a pension/provident/retirement annuity fund member, I hereby apply for the number of units that can be purchased by the investment amount referred to below in the Old Mutual Unit Trusts Living Annuity. All transactions are subject to the conditions of the relevant trust deed(s). Do you already have an Old Mutual Unit Trusts investment? No Yes If Yes, please provide unit trust number 1. ANNUITANT DETAILS INDIVIDUAL IN WHOSE NAME INVESTMENT IS HELD Surname and initials Title and first names Gender: Male Female Marital status: Married Single ID/Passport number Income tax number INDIVIDUAL IN WHOSE NAME INVESTMENT IS HELD of birth Nationality If passport, place of issue Tel. (Code) (Home) (Code) (Work) Fax Cellphone Language Preference: Eng E-mail address Postal address Afr Preferred method of communication: E-mail Postal Physical address Postcode Postcode Page 1 of 6

2. TRANSFERRING RETIREMENT ANNUITY, PENSION OR PROVIDENT FUND DETAILS Name of Fund Postal address Contact person Postcode Tel. Code Fax. Code E-mail Number Number Replacement: Does this policy qualify as a replacement policy in terms of the LOA Code on Replacement? Yes No Old Mutual s bank account details for transfers to this annuity are as follows: Bank Account Number Branch Branch Code Account Type Standard Bank 070071780 Cape Town 05 10 01 Current 3. ANNUITANT BANK DETAILS Payments can only be made to your own South African bank account. Surname of account holder Initials Bank and branch Branch code and account number Account type: Current Savings 4. COMPULSORY PURCHASE ANNUITY DETAILS Unit trust minimums apply. Distributions are automatically reinvested. No additional withdrawals, other than regular income withdrawals, are allowed. Please refer to Selecting an income level in light of investment risk further on in this form for important information before completing this section. Amount to be invested R (min. R50 000) I wish to receive an annuity income MONTHLY 3-MONTHLY 6-MONTHLY YEARLY at a gross rate of % per annum. UNIT TRUST SELECTION AMOUNT TO BE INVESTED ANNUITY INCOME Rand amount or % % of income drawn per fund TOTAL R 100% 100% of Gross Annuity Rate Page 2 of 6

5. BENEFICIARIES You can elect a beneficiary/beneficiaries on this investment. If you have more than two beneficiaries, please attach their details to this form. If no beneficiary is elected, your estate receives the remaining capital. 1. Surname and initials Title and first names % Gender: Male Female Relationship Benefit Share ID/Passport number of birth Language preference Eng Afr Nationality 2. Surname and initials Title and first names % Gender: Male Female Relationship Benefit Share ID/Passport number of birth Language preference Eng Afr Nationality 6. INCOME TAX DETAILS The income you draw is taxed at the marginal tax rate. Investment returns generated by this annuity are currently not taxable. Tax (SITE and PAYE, if applicable) will be deducted unless an income tax directive is provided. Note that payouts to beneficiaries may be subject to taxes. Additional tax per month (if required): Income tax ref. no.: 7. SHARI AH-COMPLIANT UNIT TRUSTS (Old Mutual Albaraka Equity Fund and Old Mutual Albaraka Balanced Fund) I acknowledge that I have opted to invest into a Shari ah-compliant unit trust, which means that it will be managed in accordance with the guidelines of the Shari ah Supervisory Board and having regard to the Shari ah Standards of the Accounting and Auditing Organisation for Islamic Financial Institutions (AAOIFI). I agree that any income deemed to be non-permissible by the Shari ah Supervisory Board will be paid to the charitable trust elected by the Shari ah Supervisory Board in line with the principles of Shari ah and the supplemental deed of the unit trust. I acknowledge that this does not form part of my income and will not reflect on my tax certificate. I take note that in some instances, income may be reflected as interest income in line with current tax practices on my tax certificate, but accept that such income is fully Shari ah compliant and has been approved as such by the Shari ah Supervisory Board. Signature of investor 8. ACCEPTANCE OF ADVICE A OR B I am solely responsible for my investment choices and their associated outcomes, and acknowledge that I have entered into this transaction without obtaining financial advice as that is my preference. I hereby confirm that, where applicable, the relevant intermediary (adviser or broker) has satisfied me that he/she is authorised to render financial services in respect of this product. Do you want to appoint this intermediary as your Preferred Servicing Intermediary (PSI) for all your future Old Mutual financial services needs? YES, I appoint and give the PSI access to information on all my existing Old Mutual financial services products. NO, I will complete an Intermediary Appointment Note (IAN) selecting my servicing intermediary of preference per category of Old Mutual financial services product. Page 3 of 6

9. INSTRUCTION FOR PAYMENT OF ADVISER FEES (If applicable) An initial adviser fee has been agreed as follows. The applicable amount will be deducted prior to the purchase of units. % incl. VAT (Max 1.71% incl. VAT) which is R (incl. VAT) (Note: If % and rand amount differ, the % holds.) Your adviser may receive a maximum initial adviser fee of 1.71% (incl. VAT) of the investment amount as a portion of the initial charge. The amount of the adviser fees on this policy is outlined in the OMUT Illustrator Quote Package. Advisers employed by Old Mutual Personal Financial Advice receive remuneration partly in the form of reduced adviser fees and partly in the form of other benefits. The PWM financial consultant is a permanent employee of Private Wealth Management, a business of Old Mutual. The consultant is remunerated by way of salary and performance bonus. Signature of investor ANNUAL ADVISER FEE In addition, you may elect to pay an ongoing annual adviser fee. This fee is negotiated between yourself and your adviser and is over and above the initial adviser fee stipulated above. YES or NO If yes, specify percentage. % (max 1.14% p.a. incl. VAT) of your Old Mutual Unit Trusts Living Annuity s market value as at the investment start date and thereafter on the anniversary date. Note that this instruction overrides all existing annual adviser fee agreements. This annual fee is calculated as a percentage of the value of all your member-owned Old Mutual Unit Trusts Living Annuities as at your last investment anniversary date. It excludes the Old Mutual International Growth Fund of Funds, the Old Mutual Albaraka Equity Fund, Old Mutual Income Fund A3 and Old Mutual Balanced Fund A3 as they pay a trail fee out of their annual service fee. This annual adviser fee is deducted from your scheduled annuity payments after tax has been deducted, and paid to your servicing intermediary. Payment of this fee starts on your next annuity payment. You will receive confirmation of the implementation of this fee, any adjustments made to the annual percentage or to the unit trust, as well as the cancellation thereof. This fee is based on an agreement between the client and the intermediary. You need to take into account whether your intermediary is VAT registered. Old Mutual Unit Trusts is not a party to the agreement and will cancel the fee on the written instruction of either party. The fee will further be cancelled by a change in servicing intermediary. Old Mutual Unit Trusts will change any erroneous instructions received, but will not rectify prior payments based on erroneous instruction. Signature of investor 10. DECLARATION BY ADVISER/BROKER SPECIAL INSTRUCTIONS I, the undersigned, hereby declare and warrant that I am duly authorised to render financial services in respect of this product. All parties concerned have been identified and verified and all relevant documentation has been obtained and appropriate procedures have been applied in accordance with FICA (Act 38 of 2001). Name of introducer Branch Intermediary/Broker code Tel. no. Introducer s e-mail address Are you registered with the LOA to market life assurance? YES NO I further declare that I: fully understand and accept the S referencing system; and fully understand replacement of an insurance policy contract. Signature of introducer Page 4 of 6

11. DISCLOSURES SELECTING AN INCOME LEVEL IN LIGHT OF INVESTMENT RISK The Old Mutual Unit Trusts Living Annuity is a living annuity which provides the annuitant with the flexibility to elect their income level. You can review your income level annually on the anniversary date of the annuity. This income level is currently between 2.5% and 17.5% p.a. of the portfolio value, but it may be reviewed from time to time. As performance is dependent on the underlying unit trusts selected, the value of the annuity (and consequently annuity payments) can increase or decrease. This annuity is not guaranteed. Selecting a high initial income level may further impair your ability to generate an income in future, especially if the income level is in excess of the growth of the portfolio and you are eroding capital. We thus recommend that this should not be your sole source of retirement income. In addition, if you require a pre-tax annuity of more than inflation plus 2% of the consideration in order to sustain your lifestyle, then rather consider a different type of investment. In light of the current economic environment Old Mutual recommends a maximum income level of 12%. We urge you to consider the following guidelines when deciding on your annuity income level. Under age 70: Between 70 and 80: Over age 80/ill health*: Maximum 12% p.a. Maximum 15% p.a. Maximum 17.5% p.a. * If you are suffering from ill health or some other impairment that will significantly reduce your life expectancy. Please make sure you have read this accompanying fact sheet. You can diversify your portfolio by investing in any of the funds offered in this product, thus aiming to manage investment risk. Note investors should consider both volatility risk and inflation risk in structuring a portfolio. You may switch between, Old Mutual Unit Trust funds at any time. INFORMATION Full details of unit trusts, including performance, investment objectives, risk factors and fees, are available at www.omut.co.za. RIGHT TO CANCEL This policy is a living annuity and as such is not subject to cancellation. However, you may transfer your living annuity to another insurer at any time. In addition, it may be converted to a conventional life annuity, administered by the same assurer or another assurer. A conversion is based on the market value of the units at the date of conversion, and subject to ruling legislation at the time. POLICY AMENDMENTS Old Mutual reserves the right to amend the member s benefit in the event of a change in the basis of taxation or rate. OWNERSHIP Ownership of the underlying assets of this annuity vests in the assurer, not the annuitant. EXPENSE CHARGES Potential initial product charges: Should you use an intermediary, the agreed initial adviser fee of between 0% and 1.71% (incl. VAT) of the investment amount will be deducted prior to the purchase of units. Charges against the underlying funds: An annual service fee is calculated on the market value of a unit trust s assets (excluding income and permissible deductions) and is deducted from each underlying unit trust s portfolio on a monthly basis. This fee may include payment of adviser fees. Further costs incurred by the fund may be deducted from its portfolio. These are compulsory and bank charges, brokerage, marketable securities tax, other taxes and levies, custodian and trustee fees, and audit fees. The majority of these underlying fees are jointly reflected in the Total Expense Ratio (TER) of a unit trust, disclosing the historical fees paid over a one-year period. Refer to individual unit trust fund fact sheets for these figures. A schedule of charges, fees and commission is available from the administrator. Annuity income payment fee: Dependent on payment frequency and deducted from after-tax annuity payments: R9 per month R15 per quarter R24 per half-year R42 per annum The charges outlined in our Illustrator are the full expenses that will be charged to your policy. These charges are used by Old Mutual to cover all costs of administration as well as the commission payable to the financial adviser. 12. PROTECTION OF PERSONAL INFORMATION The Old Mutual Group would like to offer you ongoing financial services and may use your personal information to provide you with information about products or services that may be suitable to meet your financial needs. Please SMS your ID number to 45600 if you would prefer not to receive such financial services. To view our full privacy notice and to exercise preferences, visit our website on www.oldmutual.co.za. Page 5 of 6

13. STATUTORY INFORMATION Unit trusts are generally medium- to long-term investments. Past performance is no indication of future performance. Shorter term fluctuations can occur as your investment moves in line with the markets. Fluctuations or movements in exchange rates may cause the value of underlying international investments to go up or down. Unit trusts can engage in borrowing and scrip lending. The fund s TER reflects the percentage of the average Net Asset Value of the portfolio that was incurred as charges, levies and fees related to the management of the portfolio. A higher TER does not necessarily imply a poor return, nor does a low TER imply a good return. The current TER cannot be regarded as an indication of future TERs. A schedule of fees, charges and maximum commissions is available from Old Mutual Unit Trust Managers Ltd (OMUT). You may sell your investment at the ruling price of the day (calculated at 15h00 on a forward pricing basis and 17h00 at month-end for Old Mutual RAFI 40 Tracker Fund, Old Mutual Top 40 Fund and SYm metry Equity Fund of Funds). The Old Mutual Money Market Fund unit price aims to be static but investment capital is not guaranteed. The total return is primarily made up of interest (declared daily at 13h00), but may also include any gain/loss on any particular instrument. In most cases this will merely have the effect of increasing or decreasing the daily yield, but in an extreme case it can have the effect of reducing the capital value of the fund. Specialist equity funds may hold a greater risk as exposure limits to a single security may be higher. A feeder fund is a portfolio that, apart from assets in liquid form, consists solely of participatory interests in a single portfolio of a collective investment scheme. A fund of funds unit trust invests only in other collective investment schemes, which may levy their own charges. Certain funds may be capped to be managed in accordance with their mandates. Different classes of units apply to these portfolios and are subject to different fees and charges. Old Mutual Unit Trust Managers Ltd is a member of the Association for Savings and Investment South Africa (ASISA). The trademarks Research Affiliates, Fundamental Index, Fundamentals Weighted and RAFI are the exclusive intellectual property of and are being used under licence with Research Affiliates, LLC. Any use of these trade names and logos without the prior written permission of Research Affiliates, LLC is expressly prohibited. Fundamental Index, the non-capitalisation method of creating and weighting an index of securities, is the patent-pending property of Research Affiliates, LLC. (Patent Pending. Publ. Nos. US-2005-0171884-A1, US-2006-0015433-A1, US-2006-0149645-A1, US-2007-0055598-A1, WO2005/076812, WO 2007/078399 A2 and EPN 1733352.) 14. DECLARATION I understand and agree that: 1. The application form and related documents, together with the policy document, form the sole basis of the contract. 2. This policy, underwritten by Old Mutual, is subject to the conditions of the contract (as amended from time to time). The policy is subject to the provisions laid down by the Registrar of Long Term Insurers and the South African Revenue Services. 3. The annuity is payable for life. The administrator reserves the right to vary the income percentage in exceptional circumstances. I understand that the annuity is not guaranteed and will depend on the income percentage selected and the investment returns of the selected unit trust funds. 4. The amount of the annuity may be reviewed annually in accordance with the annuity conditions. 5. The investment in the selected investment portfolio will be made at the ruling price on the date of receipt of the investment amount, supported by this duly completed instruction to Old Mutual, provided all statutory disclosure requirements have been met, and that payment of the annuity can commence within the first month thereafter. 6. An administration fee will be levied on all annuity income payments. 7. All information given in this instruction, and in all documents that have been or will be signed by me in connection with this instruction, whether in my handwriting or not, is true and complete. 8. I know that the cost of buying units may include an initial adviser fee charge plus VAT, depending on whether or not I use an intermediary, and that there are no guarantees on my capital. 9. I do not have a contractual right to cancel this policy. 10. No cessions/transfers/pledges/attachments and repurchases are permitted. 11. I can request a copy of this application, which must be given to me within a reasonable time of my request. 12. I am aware of the investment portfolios objectives, risk factors, the charges and income distributions as set out in the fund fact sheet(s). 13. I acknowledge that Old Mutual Unit Trust Managers Ltd may borrow up to 10% of the portfolio to bridge insufficient liquidity. 14. I further authorise Old Mutual Unit Trust Managers Ltd to accept instructions from me via facsimile (please delete if not applicable). 15. I acknowledge that I have read and understand the Old Mutual Unit Trusts Living Annuity fact sheet. Quote version number: Signature CONTACT DETAILS Old Mutual Unit Trust Managers Limited (Registration no. 65/08471/06) Mutualpark, Jan Smuts Drive, Pinelands 7405, South Africa PO Box 207, Cape Town 8000, South Africa Telephone no.: +27(0)21 503 1770 Helpline: 0860 234 234 Fax no.: +27(0)21 509 7100 Internet address: www.omut.co.za E-mail: unittrusts@oldmutual.com Complaints: Write to our Client Services Manager at the above address or call 0860 234 234. Compliance Department: +27(0)21 503 1770 Old Mutual Investment Administrators (Pty) Ltd (Registration no. 1988/003478/07) Mutualpark, Jan Smuts Drive, Pinelands 7405, South Africa PO Box 5408, Cape Town 8000, South Africa Telephone no.: +27(0)21 503 1770 Fax no.: +27(0)21 509 7100 Compliance Department: +27(0)21 503 1770 Professional indemnity cover and fidelity insurance cover are in place. Old Mutual Investment Administrators (Pty) Ltd is a third party administration and service provider to Old Mutual Unit Trust Managers Limited and is a licensed financial services provider. Visit www.omut.co.za for unit trust information, prices and news. Log in to view your portfolio online. Clients who select e-mail as their preferred correspondence method benefit from an enhanced communication offering. Page 6 of 6