aeb2099 02/2013 application form · pdf fileaeb2099 02/2013 application form for: ... the...

AEB2099 02/2013

Application form for:

Sanlam Nimbus Investments • E45

Sanlam Cumulus Investments • E40

Sanlam Cumulus Retirement Annuity• R30C

Sanlam Cumulus Pension/Provident Preserver• PP5, PF5

If this application must be handled together with other applications which were submitted, provide the plan number(s).

Plan number(s)

• Sanlam Life Insurance Limited is referred to as Sanlam Life.

• Headings marked with a ► and the accompanying paragraphs, must be completed by the Sanlam adviser or broker as applicable.

• The fully completed application form must be signed by the client.

• Please answer all questions fully in block letters, mark squares clearly with and use black ink.

• Sanlam Nimbus Investments are issued under the insurance licence of Safrican Insurance Company Limited (Safrican)* and Sanlam

Cumulus Investments are issued under the insurance licence of Sanlam Developing Markets Ltd*, both which are administered by

Sanlam Life Insurance Limited (Sanlam Life)*. Sanlam Cumulus Retirement Annuity and Sanlam Cumulus Pension/Provident Pre-

server are issued under the insurance licence of Sanlam Life. *Members of the Sanlam Group and Licensed Financial Services Providers.

An explanation for retirement annuity only

A person who wants to receive retirement annuity benefi ts, must become a member of a retirement annuity fund. To provide the benefi ts to the member, the retirement annuity fund takes out a plan on the life of the member. The retirement annuity fund, and not the member, is the planholder.

In this application you, the intended life insured, apply

• to become a member of the Central Retirement Annuity Fund (the FUND)

• and at the same time on behalf of the FUND, for a plan on your life which will fund the retirement benefi ts you wish to receive.

If this application is approved, Sanlam Life will issue the plan to the FUND. The FUND will be the planholder. You will receive a copy of the document in which the plan is recorded.

As required by the Pension Funds Act the member must pay contributions directly to Sanlam Life, and not to the FUND. Sanlam Life re-ceives the contributions as the payments on the plan.

Product name code

An explanation for pension/provident preserver only

A person who wants to preserve retirement fund benefi ts in a preservation fund must be a member of the relevant preservation fund. Thepreservation fund invests the benefi ts received, on behalf of the member in a plan on the life of the member. The preservation fund, and notthe member, is the planholder.

In this application you, the intended life insured, apply:

• to become an active member of the Sanlam Preservation Provident Fund/Sanlam Preservation Pension Fund (the FUND).

• and at the same time on behalf of the FUND, for a plan on your life which will fund the retirement benefi ts that you wish to receive.

If this application is approved, Sanlam Life will issue the plan to the FUND. The FUND will be the planholder. You will receive a copy of the document in which the plan is recorded.

As required by the Pension Funds Act the transferring fund must pay your retirement benefi ts directly to Sanlam Life and not to the FUND. Sanlam Life receive the retirement benefi ts as the payment on the plan.

Where Sanlam Life refers to the initial one-off payment it is the benefi t which will be transferred to Sanlam Life.

Plan number

Please complete pages 1 to 12 and then the relevant Annexure(s). Tick Annexure(s) you need to complete.

Annexure 1 (page 12) Details of applicant if applicant and life insured differ.

Annexure 2 (page 13) Cession, nomination for plan-ownership, authorised correspondent and Reality.

Annexure 3 (page 14 to 18) Rider benefi ts, occupation and activities of life insured, additional underwriting information, statement of health by life insured and declarations by applicant and life insured for HIV/other tests and/or other insurance information.

Annexure 4 (page 19) Acknowledgement of transfers between approved funds.

Replacement policy advice record (page 20 to 22).

With rider benefi ts Without rider benefi ts

Number of lives insured

Is this a tele-underwriting application? (If “Yes”, do not complete Annexure 3 paragraph 4(A) and (B). Para-graph 3.4 of Annexure 3 must be completed)

(Applicable to Sanlam Cumulus Retirement Annuity)

NoYes

Contact numbers (as dialled from South Africa)

Identifi cation document

Male

Eng Afr

Single Co-habiting Married Divorced Widowed

RSA Other Country

Date of birth

Surname

Maiden name

Full fi rst names

Postal address (Start each line on the left)

Postal/Zip code

Residential address (if different from postal address) (Start each line on the left)

Postal/Zip code

e-mail address

Existing plan numberSanlam Life planholder?

GenderMarital status

Correspondence languageHome language

Country of issue (of above-mentioned document)

Passport expiry date

Preferred name

Type of identifi cation Number

Present citizenship

Title

Mr Mrs Miss Ms Rev Prof Adv JudgeDr

No Yes

Female

D D M M C C Y Y

D D M M C C Y Y

Is this life insured the applicant?

(only one applicant is allowed)

1. Details of life insured

Life insured number

Make copies of this page if more lives insured apply – maximum 10. Adjust page number for additional pages, for example Page 2.1 etc. and mark clearly the life insured numbers.

NoYes

(If “Yes”, the Personal Client Details (per plan) can be attached to this ap-plication. It is then not necessary to complete the life insured’s details here)

International dialling code Area code Number

Telephone (work)

Telephone (home)

Fax (work)

Fax (home)

Cell/Mobile n.a.

Passport

(If “No”, provide the details of applicant in Annexure 1)

4. Tax dispensation

• a natural person?

Is the planholder

• a trust, where all the trust benefi ciaries are natural persons?

Name of employer

The employee was in the service of the employer from to

Certifi ed as true and correct to the best of my knowledge.

_____________________________________ ________________________________________

Offi cial stamp of employerManager / Secretary (Employer)Date (DDMMCCYY)

2. Details and declaration of employer (Only applicable to Sanlam Cumulus Pension/Provident Preserver)

D D M M C C Y Y D D M M C C Y Y

3. Market segment, income and employer of life insured (if retirement annuity) / applicant

Market segment of applicant/life insured

If the applicant/life insured is an individual, specify

Is the applicant/life insured

a Iegal entity (e.g. company/fi nancial institution)?

an individual?

99

Income (regular salary or taxable earnings from occupations)

Applicant/Lifeinsured

Spouse (if appli-cant/life insured is married)

Annual taxable income from other sources

Employer’s details

Worksite/Niche code

R p.m. R p.m. R

Employer

Town/City/Suburb

Employed

Other

Self-employed – Business owner / Entrepreneur 32 Self-employed – Farmer 33 Self-employed – Professional 36

Salaried professional – paid by someone 37 Salaried employee – paid by someone 31

Home executive 34 Minor / Scholar 35 Retired 38 Student 39 Unemployed 40

Self-employed

*If retirement fund is marked, provide the FSB number

FSB number (non-Sanlam Funds) 1 2 / 8

• a retirement fund?*

5. ► Revocable benefi ciaries/nominees (Indicate % benefi t accruing to each in the last block)

Note • If applicant is married in community of property and the spouse is not the only benefi ciary/nominee, complete form AE3000 (not applicable to retire-ment annuities).

• If any benefi ciary is still a minor at my demise, I instruct Sanlam Life, by signing this application, to transfer the death benefi t directly to the Sanlam Guardians’ Trust until the minor turns 18, subject to the stipulations as set out in form AE3000.

Life insured number

Title

Full fi rst names

NumberType of identifi cation

Maiden name

Date of birthCorrespondencelanguage RelationshipGender

Country of issue(of above-mentioned document)


Postal/Zip code

Male Female Eng AfrD D M M C C Y Y

Surname

Percentage of benefi t

%

Make copies of this page if more benefi ciaries/nominees apply. Adjust page number for additional pages, for example Page 4.1 etc. and mark clearly the life insured numbers.


Title

Full fi rst names

NumberType of identifi cation

Maiden name

Date of birthCorrespondencelanguage RelationshipGender

Country of issue(of above-mentioned document)


Male Female Eng AfrD D M M C C Y Y

Surname


Identifi cationdocument Passport Foreign ID


Postal/Zip code

Percentage of benefi t

%

Benefi ciary/Nominee 1: Is this benefi ciary/nominee also a life insured?

If “Yes”, only complete surname, full fi rst names, date of birth and percentage of benefi t in the block below

NoYes

Benefi ciary/Nominee 2: Is this benefi ciary/nominee also a life insured?

If “Yes”, only complete surname, full fi rst names, date of birth and percentage of benefi t in the block below

NoYes

6. Debit order details

I, the undersigned, request Sanlam Life to arrange with my bank/employer and Multi Data to collect the payments due on the plan (as they may be amen-

ded from time to time) from my bank account (wherever it may be) by debit order.

Details of account holder/payerIf the payer is not the same person as the applicant for this plan, complete A and C or B and C. D must always be completed.

A. Natural personFull names and surname

Telephone (work) ( )

Company Close corporation Trust Deceased estate Partnership Other legal person Fund

Name of bank

6-digit branch code

D. Bank details

Account number


Title Gender

Postal code

Contact number

B. Legal entityName of legal entity

Legal entity type

Registration number Country of registration

C. Contact details

Type of identifi cation Number

Male Female

Branch

(If cheque account, attach cancelled cheque)Type of account (If Bob 2000 account it must be linked to a current account) Date of fi rst withdrawal (must be on or nearest to salary pay day)

D D M M C C Y Y


Current Transmission Savings

PassportIdentifi cation

document

Telephone (home) ( )

D D M M C C Y Y

Date of birth

Date (DDMMCCYY)Signature of payer or authorised offi cial

____________________________ _____________________________________________

Must the payments in arrears, if applicable, be collected additionally with the fi rst withdrawal?

Can Sanlam Life alter the debit order deduction day as follows so that it comes into operation in time? (Please choose one)

• The same deduction day one month in advance

• Any date that is in time in that month

• Move to the fi rst of the next month

If a retirement annuity and the premium payer is an institution

We hereby declare that

• we understand and are aware that Section 13A of the Pension Funds Act, 1956 is applicable and the implications thereof

• contributions do not qualify for tax deduction in terms of Section 11(l) of the Income Tax Act, 1962

• participation for employees is on a voluntary basis and not compulsory.

NoYes

Note: • Cash payment details must be fi lled in at paragraph 7.

• Initial term

Initial one-off payment•

Start date•

8. Details of plan Date of quotation

R/c

D D M M C C Y Y

D D M M C C Y Y

May Sanlam Life change the start date of the plan according to circumstances? No Yes

9. ► Replacement of a fi nancial product

IMPORTANT NOTE: Replacement of any fi nancial product is generally always to the disadvantage of the planholder (applicant)/life insured because it involves duplication of initial costs charged to the fi nancial product.

Is this application to replace the whole or any part of your existing fi nancial product provision (reduction of payments on existing product provision is inclu- ded) with any fi nancial product provider (whether replacement is to occur immediately or to replace a fi nancial product discontinued within the past four months or within the next four months)? If “Yes”, the Sanlam adviser must discuss the relevant replacement disclosures and product comparison contained in the Record of Advice or Record of Product Guidance with you. The form must be completed in full and attached to this application form.

Furthermore, if ”Yes” and a long-term insurance policy was or is to be replaced by another long-term insurance policy, the intermediary (broker or Sanlam adviser) must discuss the Replacement Policy Advice Record [RPAR form (AE2794)] with you, complete it in full and attach it to this application form.

Please note that in the case of a replacement there will not be a transaction on the existing plan to cancel it, reduce its payments or to make it paid-upautomatically. If the applicant’s/life insured’s intention with the replacement is to perform any such transaction on the existing fi nancial product, the appli-cant/life insured (with the assistance of the intermediary, where appropriate) must make the necessary arrangements to effect such transaction on the replaced fi nancial product.

No Yes

5 years

(The start date for Sanlam Cumulus Pension/Provident Preserver is determined by the date on which the initial one-off payment is received)

(Applicable to Sanlam Nimbus Investments, Sanlam Cumulus Investments and Sanlam Cumulus Retirement Annuity)

(Applicable to Sanlam Cumulus Investments)

Actual retirement date or Actual retirement age• D D M M C C Y Y

(Applicable to Sanlam Cumulus Re- tirement Annuity and Sanlam Cumulus Pension/Provident Pre- server)

Source of initial one-off payment (Applicable to Sanlam Cumulus Pension/Provident Preserver)

Pension Fund Provident Fund Preservation Pension Fund Preservation Provident Fund Pension interest from divorce

Recurring payment• R/c (Only applicable to Sanlam Cumulus Retirement Annuity)

Retirement Annuity policy LISP Retirement plan Pension/Provident Fund

• Type of initial one-off payment Optional Compulsory

Source of initial one-off payment if type is compulsory

Pension interest from divorce

• Payment growth: Fixed growth (Choice: 5% to 20%)

No growth

%

Sanlam Infl ation

and/or

Monthly Annually

Debit order

Frequency:

Mode of payment:

•

Internal recurringfunding

If mode of payment is internal recurring funding: Term annuity (non – Stratus) / Life annuity policy number

Sanlam Employee Benefi ts reference number

or

•

(Applicable to Sanlam Cumulus Retirement Annuity)

•

7. Cash payment details

Name of bank (state branch) Account number

R/c

Amount paid Date

Cash payment number

Deposit: Internet ATM Cashier at bank: Cheque or Cash

D D M M C C Y Y

%

%

%

%

%

%

%

%

%

*Allan Gray Stable Fund (703/602/622)

*Coronation Balanced Plus Fund (709/612/630)

Coronation Money Market Fund (616/633) (not applicable to Nimbus)

Investec Equity Fund (604/624) (not applicable to Nimbus)

Investec Property Equity Fund (712/618/634)

Nedgroup Investments Rainmaker Fund (705/606/625)

SIM General Equity Fund (609/628) (not applicable to Nimbus)

*Allan Gray Balanced Fund (702/601/621)

Allan Gray Equity Fund (701/600/620)

Old Mutual Mining and Resources Fund class A (710/614/631)

%

%

*SIM Balanced Fund (706/607/626)

%Allan Gray Orbis Global Equity Feeder Fund (713/619/635)

10. Investment Funds (Funds marked with an asterisk (*) are Regulation 28 compliant)

Fund nameAllocationpercentage

%

*Sanlam Escalating – SIM Balanced Fund (654/669) (not applicable to Nimbus)

%

%

%

%

%

Sanlam Escalating – Nedgroup Investments Rainmaker Fund (653/668)(not applicable to Nimbus)

Sanlam Escalating – Coronation Equity Fund (663/676) (not applicable to Nimbus)

Sanlam Escalating – Old Mutual Mining and Resources Fund class A (657/671) (not applicable to Nimbus)

*Sanlam Escalating – Allan Gray Balanced Fund (651/666) (not applicableto Nimbus)

Sanlam Escalating – Allan Gray Equity Fund (650/665) (not applicableto Nimbus)

Sanlam Escalating – Investec Equity Fund (652/667) (not applicable to Nimbus)

Sanlam Escalating – Coronation Top 20 Fund (658/672) (not applicable to Nimbus)

%

%

%Sanlam Escalating – SIM General Equity Fund (655/670) (not applicable to Nimbus)

%Sanlam Escalating – SIM Value Fund (664/677) (not applicable to Nimbus)

%

%

Sanlam Escalating – Allan Gray Orbis Global Equity Feeder Fund (661)(not applicable to Nimbus, RA and Pension Provident Preserver)

*Sanlam Escalating – Coronation Balanced Plus Fund (662/675) (not ap-plicable to Nimbus)

%*Coronation Balanced Defensive Fund (714/644) (not applicable to Cumulus Investments)

%*Coronation Capital Plus Fund (645) (not applicable to Nimbus and Cumulus Investments)

%Coronation Equity Fund (704/603/623)

%Coronation Strategic Income Fund (643) (not applicable to Nimbus and Cumulus Investments)

%Coronation Top 20 Fund (711/615/632)

%*Foord Balanced Fund (680) (not applicable to Nimbus and Cumulus Invest-ments)

%Foord Equity Fund (647) (not applicable to Nimbus and Cumulus Investments)

%*Investec Managed Fund (646) (not applicable to Nimbus and Cumulus In-vestments)

%*SIM Active Income Fund (715/682) (not applicable to Cumulus Investments)

%*Investec Opportunity Fund (700) (not applicable to Cumulus Investments, RA and Pension/Provident Preserver)

10. Investment Funds (Funds marked with an asterisk (*) are Regulation 28 compliant) (continued)

Fund nameAllocationpercentage

%SIM Money Market Fund (708/610/629)

SIM Value Fund (707/608/627) %

%*SIM Managed Aggressive Solution (640) (not applicable to Nimbus and Cumulus Investments)

%*SIM Managed Cautious Solution (637) (not applicable to Nimbus and Cumulus Investments)

%*SIM Managed Conservative Solution (636) (not applicable to Nimbus and Cumulus Investments)

%*SIM Managed Moderate Solution (638) (not applicable to Nimbus and Cumulus Investments)

%*SIM Managed Moderately Aggressive Solution (639) (not applicable to Nimbus and Cumulus Investments)

%*SIM Reg28 Property Equity Fund (642) (not applicable to Nimbus and Cumulus Investments)

PSG Konsult Funds

%PSG Konsult Moderate Fund of Funds (678) (not applicable to Nimbus andCumulus Investments)

%PSG Konsult Preserver Fund of Funds (679 (not applicable to Nimbus andCumulus Investments))

%SIM Global Best Ideas Feeder Fund (684) (not applicable to Nimbus and Cumulus Investments)

%*SIM Infl ation Plus Fund (641) (not applicable to Nimbus and Cumulus Invest-ments)

%PSG Konsult Moderate Fund of Funds (719) (only available to PSG brokers)(not applicable to Cumulus Investments, RA and Pension/Provident Preserver)

11. Declaration by life insured (if retirement annuity or pension/provident preserver) / applicant

The life insured/applicant applies for the plan indicated herein (“this plan”) – subject to the following:

1. For the application for Sanlam Nimbus Investments and Sanlam Cumulus Investments, Sanlam Life acts on behalf of Safrican and Sanlam Developing Markets as administrator of the plan.

2. I guarantee that the paragraph, Replacement of a fi nancial product has been fi lled in correctly and also that all other information herein, is complete and correct. This guarantee applies also to information which in Sanlam Life’s reasonable opinion is relevant to the insurance risk and which is contained in other documents signed or provided by me or a life insured. If any of the aforesaid information is not complete or correct, Sanlam Life may cancel this plan. If this happens, all money paid in terms of this plan will be forfeited.

3. I declare that the withdrawal benefi t payable by a fund from which I have withdrawn or will withdraw owing to my recent or forthcoming termination of service, has not been or will not be transferred to more than one preservation fund.

4. Sanlam Life’s obligations under this plan come into effect on the last of (a) the date of Sanlam Life’s written acceptance of this application; (b) this plan’s start date as mentioned in the plan document; and (c) the date on which Sanlam Life receives the one-off or fi rst payment in terms of this plan or the date on which arrangements, to Sanlam Life’s reasonable satisfaction, have been made for the payment to Sanlam Life. 5. Should the insurance risk deteriorate before Sanlam Life’s obligations in terms of this plan take effect, Sanlam Life may cancel this plan. In the event

of such a cancellation any money paid in terms of this plan will be forfeited, unless Sanlam Life, in its reasonable discretion, decides otherwise.

6. If this plan is cancelled, Sanlam Life will have the right to refund less than the amount paid up to date of cancellation, if, owing to a change in investment conditions the assets in which such amount was invested, have decreased in value during the period up to the date of cancellation.

7. Investment advice agreement between the life insured and the FUND: (only applicable to retirement annuity or pension/provident preserver)

I want to receive ongoing investment advice for my retirement investment. I understand that this advice is an optional service that is in addition to and not part of other services rendered for my retirement/retirement annuity

plan.

I request the FUND to pay a fund-based fee to the intermediary, nominated by me, who provides this advice.

I understand that I may instruct the FUND at any time to change this fee, or to stop paying it.

I understand that Sanlam Life, as the administrator of the FUND and on instruction of the FUND, will pay this fee on a monthly basis on behalf of the FUND.

I understand that this fee is deducted monthly from the fund value of my plan by means of a withdrawal to the value of the monthly fee.

I understand that this fee is linked to and fl uctuates with the fund value of my plan. I understand that the FUND is not responsible for the correctness, completeness or quality of this advice.

I agree that until I instruct the FUND otherwise, the fee payable, expressed as a yearly fee, is the percentage of the fund value specifi ed in the product quotation.

Note: No fee will be payable if not so indicated in the product quotation.

8. If this is an application for a retirement annuity, I apply for it on behalf of the RA fund concerned. If I am not yet a member of the fund, this application also serves as my application for such membership, and the rules of the fund will be binding.

9. If this is an application for cover and you have selected that the underwriting questions for such cover should be asked by telephone, Sanlam Life will consider the application for cover on the basis of what information was supplied during this telephone conversation.

10. If any rider benefi t applied for herein cannot be granted in accordance with Sanlam Life’s normal practice from time to time, Sanlam Life may, with my prior consent, limit or exclude the rider benefi t or load the payment and may then also adjust the main benefi ts of this plan in so far as it is necessary to leave unchanged the total payment indicated herein for this plan.

11. This plan will be issued in the RSA. All amounts relating to this plan – in particular payments and where applicable, surrender payments and loan payments will be expressed, calculated and paid in RSA currency. Payment will be made in the RSA.

12. I accept full responsibility for informing Sanlam Life of any changes in current identifi cation information provided (e.g. address change, surname change, contact details, etc.)

13. I am aware that in terms of the Financial Advisory and Intermediary Services Act, 37 of 2002 (FAIS), I may request a copy of any document that I or someone on my behalf submitted to Sanlam Life that pertains to this application.

14. In terms of the Prevention of Organised Crime Act (number 121 of 1998), I confi rm that the funds with which any payment is or will be made to Sanlam Life, in terms of this plan, are derived from a lawful source. In addition, I declare myself willing to answer any questions with regard to the origin of such funds and to provide additional information as and when it may be required by Sanlam Life.

15. All insurers who are members of the Association for Savings and Investment South Africa (ASISA) share plan information on a central Register to keep track of and ensure proper handling of replacement of fi nancial products, whether it concerns this application now or in future. This information is pro- tected and can only be accessed by authorised persons. To enable such authorised persons to access my plan information, I hereby give consent that my information may be used on the Register of ASISA. 16. I understand that all information in this application form will be recorded electronically in Sanlam Life’s computer system. No physical records will therefore be kept and this transaction will be regarded as having been carried out during the normal course of Sanlam Life’s business. The electronic records of Sanlam Life’s computer system will form the record of this plan for all purposes and may be used as evidence at any proceedings.

17. I accept that this plan may only be ceded, if applicable to an individual or to a trust where all the trust benefi ciaries are natural persons or for collateral security e.g. a bank. I further accept that this restriction also applies in the event of nomination for plan-ownership.

18. If risk is applicable and I am also a life insured, I hereby give consent to Sanlam Life to disclose to the intermediary any medical information that, during the underwriting process, has led to a payment loading being added, an exclusion being applied, or to the decline of the total plan or part thereof. This will enable the intermediary who has assisted me in this application to explain such loading, exclusion, or decline to me and provide me with further advice. I also give consent to Sanlam Life to provide such medical information to the doctor nominated in my application form.

Always complete the following

I declare that (i) the documents indicated below have been given to me (ii) I have read them and understand their contents, (iii) the application form (of which this declaration forms part) has been fully completed:

Health Statement Intermediary’s Permit Product Quotation Quotation number

Note: The above declaration will be validated by the required signatures at paragraph 12.

(if rider benefi tsapplicable)

12. Signatures

Signature of/for applicant – if Sanlam Nimbus Investments/Sanlam Cumulus Investment/Sanlam Cumulus Retirement Annuity or Signature of life insured/curator – if Sanlam Cumulus Pension/Provident Preserver___________________________________ Place_____________________Date (DDMMCCYY)________________________

Note: Where a life insured is a minor and the guardian/parent is the applicant, the guardian/parent must only sign as applicant. Where a life insured is a minor and the guardian/parent is not the applicant, the guardian/parent must sign on behalf of such life insured.

Signature of/on behalf of life

insured no _____________________________ ______________Place____________________Date (DDMMCCYY)_______________________

Nature of relationship of signatory to life insured if life insured a minor: ____________________________________________________________


insured no _____________________________ ______________ Place____________________Date (DDMMCCYY)_______________________








Signature of legal guardian/spouse – only if someone other than the applicant ____________________________________Place____________________Date (DMMCCYY)_______________________

Nature of relationship if legal guardian: ______________________________________________________________________________________

Note: As far as is required by law with regard to any person and/or aspect herein, the guardian/spouse grants the necessary consent and/or assistance or, de-pending on the case, acts in a representative capacity.



Nature of relationship of signatory to life insured if life insured a minor: ___________________________________________________________
















(0 – 100%: e.g. if maximum – fi ll in 100%)

13. Further information supplied by intermediaries

Note: The intermediary whose name appears next to “1” above, will be regarded as the one responsible for advice to the applicant/life insured.

Commission

Commission: as calculated and indicated on quotation INITIAL COMMISSION ON ONE-OFF PAYMENT

Declaration by intermediary

• I hereby declare that, if applicable, I have explained the meaning and possible detrimental consequences of replacement of a fi nancial product to the applicant/life insured.

• I hereby declare that I have disclosed the intermediary’s permit and product quotation to the applicant/life insured.

I hereby declare that I have identifi ed and verifi ed all the applicable parties in terms of Section 21(1) of FICA, if applicable.

• I have read point 7 of paragraph 11 (page 9) of this application form and understand the meaning of it. I agree that if Sanlam Life complies with an instruction as stated, I will have no right of recovery or any other rights or claims against either the applicant/life insured or Sanlam Life for the payment of any money to me.

I hereby declare that I am authorised to market this product and that in terms of the Financial Advisory and Intermediary Services Act and its sub-legis- lation, I have not been debarred nor has any authorisation given to me been withdrawn or suspended, or lapsed. I declare further that I am fully conver sant with and accept the S-Reference System as binding, and that there are no S-References imposed upon me.

Note: The above-mentioned % of the maximum commission permitted will be paid to the intermediary.

NoYes Did you see the RSA identity document or passport, if applicable, of the life(lives) insured and do you declare that the

information in it agrees with the information on this application form?

( )Fax E-Mail

Region Branch Brokerage

Number where you (intermediary or assistant), could urgently be contacted, if necessary:

Date of birthName of intermediary who completed the application form.

Have you identifi ed and verifi ed the information of the applicant, or the person acting on behalf of the applicant, if applicable, where the one-off payment exceeds R50 000 or the recurring payment exceeds R25 000 p.a.? (Not applicable to retirement annuity and pension/provident preserver)

Cellular: Telephone no. ( )

If “Yes”: Source of income Source of funds for this investment

%

D D M M C C Y Y

Other requests by intermediary _________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Name of broker’s consultant

SA citizen(s)/resident(s)acting on own behalf

Natural person acting on behalf of SA citizen/resident

Foreign national acting on own behalf

Person acting on behalf of foreign national

Natural person/legal person/partners for partnership/trustee for trust holding > 25% shares in RSA /foreign company

Trust benefi ciary Founder of trust

Trustee Manager of company Partner in a partner-ship

Close corporation member

Representative ofother legal person

Other capacity (specify)

Capacity of applicable party

Race (life insured (if retirement annuity)/applicant) (for statistic purposes)Asian ColouredBlack White

Date (DDMMCCYY) ► Signature of intermediary► Co-signature of key individual where theintermediary is a Sanlam adviser who must

still provide proof of the required product skills

____________________________ _____________________________________________ _____________________________________________

Initials and surname of intermediary(ies) Code

Bank brokers Splitting of commission %

Man code Reference number

Recurring payment One-offpayment Fund-

based feeInitial

commission

Payment-based

commission

Initial commission

1.

2.

3.

4.

(0 – 50%: e.g. if maximum – fi ll in 50%) (0 – 100%: e.g. if maximum – fi ll in 100%)

Amount

INITIAL COMMISSION ON RECURRING PAYMENTS

Amount (per month/year)

PAYMENT-BASED COMMISSION ON RECURRING PAYMENTS

Commission Commission

R/c

%

R/c

%


C. Contact details

Male

Eng Afr

Single Co-habiting Married Divorced Widowed

Surname

Maiden name

Full fi rst names

GenderMarital status

Correspondence language

Home language


Passport expiry date

Preferred name

Tax status

Postal/Zip code

Residential/Physical address (if different from postal address) (Start each line on the left)

Postal/Zip code

e-mail address

Contact numbers (as dialled from South Africa)

Female

A. Natural person

Sanlam Life planholder?

No Yes

Existing plan number

D D M M C C Y Y

Details of applicant (Not applicable to Sanlam Cumulus Retirement Annuity or Pension/Provident Preserver) (Complete only if applicant is not a life insured) (Only available for individuals or a trust where all the benefi ciaries are natural persons)

Trust

B. Legal entityName of legal entity

Legal entity type

Registration number Country of registration

(only where all the trust benefi ciaries are natural persons)

Legal entity: job title/title, surname and initials of contact person

(If “Yes”, the Personal Client Details (per plan) can be attached to this ap-plication. It is then not necessary to complete the life applicant’s details here)

Title


International dialling code Area code Number

Telephone (work)

Telephone (home)

Fax (work)

Fax (home)

Cell/Mobile n.a.

Identifi cation document

Date of birth Type of identifi cation Number

D D M M C C Y Y Passport

Annexure 1

3. Authorised correspondent

2. ► Nomination for plan-ownership (Only if applicant is not a life insured or if applicant is not the only life insured)(Not applicable to retirement annuity or pension/provident preserver)

Title

AfrEngD D M M C C Y Y


Full fi rst names

Surname

Type of identifi cation

GenderDate of birthCorrespondence language Relationship

Number



Postal/Zip code

Male Female


Title

AfrEngD D M M C C Y Y


Full fi rst names

Surname

Type of identifi cation

GenderDate of birthCorrespondence language Relationship

Number



Postal/Zip code

Male Female


(If a child between the ages of 1 day and 18 years is the life insured and/or applicant, the name and address details of his or her parent/guardian must be fi lled in here.)

1. ► Notice : Cession of plan (Not applicable to Sanlam Cumulus Retirement Annuity or Pension/Provident Preserver) (Only in favour of an individual or a trust where all the trust benefi ciaries are natural persons or for collateral security)

Has the plan been ceded? Yes If “Yes”, complete cession form, AE2170.

4. Reality (Applicable to life insured (if retirement annuity)/applicant)

No Yes Are you already a Reality member? If “No”, would you like to join the Sanlam lifestyle program Reality?

*Which option would you like to join? Reality or Reality Plus Important: If you choose a Reality option you hereby authorise the payment for the monthly membership contribution and, where possible, for it to be collected with your Sanlam plan payment. You also accept, e.g. the membership rules of benefi ts, terms and conditions and membership contributions, including that of the Reality partners, as explained to you by your intermediary. Should you need more information please call 08 22 33 5000 or visit www.reality.co.za

Yes*

Annexure 2

Make copies of this page if more lives insured apply – maximum 10. Adjust page number for additional pages, for example .1 etc. and mark clearlythe life insured numbers.

Life insured number

Annexure 3 Page 14

R p.m. R p.m. RR p.m.

Past Present

%

%

%

%

Secondary occupation/Rank

Duration of course

Employer

• Employer’s details

Description of activities of primary occupation/rank

Description of activities of secondary occupation/Rank

• Income (regular salary or taxable earnings from occupations)

State the other sources/Defence force unit

In determining the total income, any form of income from the following is excluded: overtime pay, non-taxable fringe benefi ts, interest, dividends, rental income.

State the % work per day that consists of (total % must sum to 100%)

Life insuredSpouse (if life insured is married)

State annual taxable income from sources other than your full-time occupation

Have you in the past participated in, do you currently participate in or do you intend in the future to participate in, any hobbies/activities that could be hazardous in any way, for example fl ying/gliding activities, diving, professional sports, motor-sport, bungy jumping or any other hobby/activity with a risk of accidents and/or risk to health?

If “Yes”, state the hobby/activity and give full particulars

Indicate the status of the above-mentioned hobby/activity

If “past”, state the last participation date

Please complete the specifi c forms indicated below if you are currently participating in the following activities: Motorsport (AE96); Flying (AE97): Aviation/parachuting/gliding/paragliding/hang-gliding/wing-gliding; Diving (AE98)

• Part-time/other activities

• Have you during the past 3 years participated in, or do you intend in the future to participate in, any hazardous occupation(s), for example fl ying/gliding activities, diving, professional sports, mining, motorsport, security forces, explosives handler, taxi industry, security industry/protection services, microlender industry or any other occupation with a risk of accidents or risk to health, which you have not already disclosed above?

• Academic qualifi cations

Guardian

*(Administrative work is any work not falling in the other categories, and includes the supervision of administrative personnel, or factory or workshop workers.)

Administrative work*

Manual labour

Supervision extramurally, or over travelling working teams, or over machinery

Travel, including fi eld work

• Do you smoke or have you been smoking during the preceding 12 months?

2. Occupation and activities of life insured (Applicable if risk benefi ts are taken)

Future

If “Yes”, state the occupation

School grade Std. Post matric qualifi cation(s) (e.g. ND or B.Sc)

C C Y Y

NoYes

NoYes

NoYes

years

Waiver of payment at disability

– without future growth (OPG)

– with future growth (OGG)* * Can only be taken if payment growth is Sanlam infl ation.

1. Rider benefi ts

• Occupation and description of activitiesPrimary occupation/Rank

%

%

%

%

State the % work per day that consists of (total % must sum to 100%)

*(Administrative work is any work not falling in the other categories, and includes the supervision of administrative personnel, or factory or workshop workers.)

Administrative work*

Manual labour

Supervision extramurally, or over travelling working teams, or over machinery

Travel, including fi eld work

Life insured number

Make copies of this page if more lives insured apply – maximum 10. Adjust page number for additional pages, for example .1 etc. and mark clearlythe life insured numbers.

Page 15

Call times

Any time between 8h00 and 20h00 or Between and (Call times may not be before 8h00 or after 20h00)

3. ► Additional underwriting information (per life insured)

AfrEng

3.1 Insurable interest

Have you submitted any other applications for risk plans to-gether with this one?

If “Yes”, provide total number of such appli-cations

Plan number(s) (if available)

3.3 Residence outside RSA

Are you currently in a foreign country or are you planning to travel to a foreign country during the next 12 months?

If “Yes”, complete form, Residence outside RSA – EVL07

Nature of relationship/insurable interest to the applicant (fi nancial loss to applicant at death of life insured)

3.4 Tele-underwriting (Please give the informaton sheet for tele-underwriting, TU0001E, to the client)

Note: Tele-underwriting is not available when rate group 1 is applicable.

Preferred language

3.2 Other applications

Contact numbers Area code Number

Telephone (work)

Telephone (home)

Cell/Mobile n.a.

cm kg

Length Weight

OtherSpouse Guardian Child

Specify if “Other”

NoYes

NoYes

4(A). ► Statement of health by life insured (Applicable if risk benefi ts are taken)

Life insured number

Initials and surname

Date of birth

D D M M C C Y Y

If the answer to any question (excluding questions 9, 10, 13, 15 and 16) is “Yes”, please give question number and full details on the next pages. Yes No1. 1.1 Has an application for life, medical, disability or dread disease insurance (e.g. heart attack) on your life ever been

declined, postponed, withdrawn or accepted on special terms or at special rates?

1.2 Have you ever submitted a disability benefi ts, accident benefi ts or trauma benefi ts claim (the latter as a result of a dread disease) to any insurer or fund?

2. Do you have, or have you ever had any of the following

2.1 (a) Any disorder of the heart, blood vessels or circulatory system (e.g. high blood pressure, chest pain, heart murmurs, palpitations, coronary thrombosis, shortness of breath, tightness of chest, stroke or raised cholesterol)?

(b) Any disorder of the heart, blood vessels or circulatory system including calf cramps during light or moderate exercise or walking?

2.2 Respiratory or lung trouble (e.g. asthma, recurrent bronchitis, persistent cough, tuberculosis (TB), blood vomiting or tightness of chest)?

2.3 Disorder of the digestive system and liver (e.g. gastric or duodenal ulcer, recurrent indigestion, jaundice, hepatitis, liver disease or rectal bleeding)?

2.4 Disease or disorder of kidneys, bladder or reproductive organs (e.g. kidney-stones, infections, blood or albumin in urine, prostatitis, trouble to pass urine or venereal disease)?

2.5 Any nervous or mental complaint (e.g. fi ts, depression, anxiety or stress related disorders, persistent headaches, blackouts, epilepsy or paralysis)?

2.6 Eye, ear, nose or throat disorders (e.g. defective vision, deafness, recurrent ear infections, balance disturbance, im-

paired speech or hoarseness)? 2.7 (a) Any disorder or disease of spine, joints, muscles, bones, limbs (e.g. backache, slipped vertebrae/disc prolapse

or any other back or neck trouble, rheumatism, arthritis, gout)?

(b) Any disorder or disease of the skin including porphyria, psoriasis or dermatitis?

2.8 Diabetes, sugar in urine, insulin resistance, leukaemia, bleeding disorders, spleen, thyroid or any other glandular and blood disease?

2.9 Cancer, growths or tumours of any kind?

2.10 Congenital mental insuffi ciency, essential defect of memory/concentration or minimal brain dysfunction?

2.11 Any disorder which affects or may affect your ability to practise your occupation (e.g. chronic fatigue, joints or skeletal problems)?

2.12 Any other disease, injury or disorder which necessitated treatment or bed rest for more than 6 days or prevented you from practising your occupation for more than a month in the past 3 years?

3. Have you ever been tested for Aids or an Aids-related illness (excluding for insurance purposes), for Hepatitis B or any other sexually transmitted disease or have you received any medical advice, counselling or treatment in respect thereof?

4. During the past 5 years have you been to any hospital, clinic, or medical institution or undergone any medical investiga-

tions (including ECG’s, X-rays or pathological tests) for other reasons than the above-mentioned?

5. Did you receive any medication or other treatment uninterruptedly for longer than six days within the past 5 years, or is this the case now, for conditions NOT already mentioned?

6. Did you consult any medical practitioner or other person who renders health services (e.g. nursing sister, herbalist, tradi-tional healer/sangoma) during the past 12 months, for conditions NOT already mentioned?

7. Have you taken any drugs like mandrax, dagga, etc. during the past 5 years?

8. Has any member of your immediate family (e.g. parents, brothers or sisters) suffered from diabetes, heart disease, high- blood pressure, raised cholesterol, porphyria, cancer or any other hereditary disease? If “Yes”, state which relative, as well as age and type of disease.

9. Have you been smoking during the past 12 months? If “Yes”, state daily use of tobacco here:

Cigarettes Cigars Pipe

10. Do you consume alcohol? If “Yes”, state type and quantity per day or per week here

11. Did you drink more regularly in the past or did you have an alcohol problem – whether or not you received treatment for it?

12 . Has your mass changed by more than 5 kg during the past year?

13. Height and mass

14. Have you undergone any medical examinations during the past 6 months for the purposes of a previous insurance application with Sanlam Life?

Q u a n t i t y p e r d a y

Type Quantity

per day per week

per day per week

Note: This statement of health will be validated by the required signatures at paragraph 12 on page 10.

cm kg


Life insured number

Initials and surname

Date of birth

D D M M C C Y Y


4(B). Details of family doctor

( )

Initials, surname and postal address of previous family doctor

Since when has he/shebeen your family doctor?

Initials and surname of family doctor

Postal address of family doctor

Telephone

( )Fax

Postal code

Postal code

D D M M C C Y Y

4(A). ► Statement of health by life insured (continued)

If the answer to any of the questions (excluding questions 1.2, 9, 10 and 13) is “Yes”, provide the number of the relevant question and the full details of such question.

ClaimDate of claim(DDMMCCYY)

Reason for claimCompany(ies) claimed from

Have you sustained permanent

disablement or injuries?

Questionno.

Date of diagnosis orlatest symptoms

(DDMMCCYY)

Describe the nature of the condition

and treatment received

Still on treatment?(Yes / No)

Have you recovered in full? (If not, describe)

If the answer to question 1.2 is “Yes”, provide details below

5(A). ► Declaration by applicant for HIV/other tests (Only applicable if rider benefi ts are taken)

5(B). ► Declaration by life insured number for HIV/other tests and/or other insurance information (Only applicable if rider benefi ts are taken)

I understand and accept that

• the lives insured have to understand and agree to all the terms and conditions set out in the lives insured declaration in paragraph 5(B), which must also be signed by him/her;

• if Sanlam Life requires the lives insured to undergo an HIV blood test

• the lives insured must undergo an HIV test before this application will be processed;

• Sanlam Life reserves the right to require the lives insured to undergo other blood tests in order to continue with the processing of this application;

• Sanlam Life will refuse to accept this application unless the lives insured undergo an HIV test and/or other blood tests required by Sanlam Life and such tests render a negative/required test result.

Note: This declaration will be validated by the required signatures at paragraph 12 on page 10.


Telelphone ( )

Postal code

Postal address of doctor

Initials and surname of doctor

1. I understand and hereby agree that if, for purposes of processing this application, Sanlam Life requires me to undergo an HIV blood test and/or another blood test

• I will undergo such a test. I understand the importance of being fully informed about my having to undergo an HIV blood test and I fully understand the implications thereof;

• any such HIV blood test must be done only according to the Association for Savings and Investment South Africa (ASISA) prescribed rules;

• Sanlam Life reserves the right to require that I undergo other blood tests and also reserves the right to require that further tests be done on the sample of my blood. If Sanlam Life requires me to undergo other blood tests, I agree to do so.

2. I agree to undergo a cotinine test to measure serum nicotine levels, if Sanlam Life requests it.

3. If, in complying with a requirement by Sanlam Life, I should undergo any HIV test and/or other blood test, I indemnify Sanlam Life and its directors, agents, intermediaries and employees, as well as the person who takes the sample of my blood and the person who performs such test on that sample, against any claim of whatever nature which may be brought against Sanlam Life and/or against any of these persons as a direct or indirect result of any such test.

4. I want the results of any abnormal blood test to be disclosed to the following party: (Please choose one)

If another nominated doctor, provide the following:

If ASISA call centre, provide the following:

Preferred language

5. Accepting that I am curtailing my right of privacy, but to facilitate the assessment of the risks, and the consideration of any claim for benefi ts under a plan related to this or any other application made in respect of me as a life insured, I irrevocably authorise Sanlam Life, for insurance (including reinsu- rance) purposes, to:

• obtain from any person or institution, whom I hereby so authorise and request to give to Sanlam Life, any information which Sanlam Life deems necessary, and

• share, at any time (even after my death), with other insurers (including reinsurers) – either directly or through a data base operated by or for insurers as a group, and in such detailed, abbreviated or coded form as may from time to time be decided by Sanlam Life or by the operators of such data base – that information and any information contained in this application or in any related plan or other document.

I indemnify Sanlam Life and its directors, agents, intermediaries and employees, as well as any other person, against any claim arising from the provi-sion and/or disclosure of such information.

6. Sanlam Life has specifi c risk products for HIV positive lives. If your HIV test result is positive, you can contact Sanlam Life at 0860 000 121, or your intermediary.

Alternatively, would you prefer Sanlam Life to contact you? Please initial if you require direct contact

Note: This declaration will be validated by the required signatures at paragraph 12 on page 10.

NoYes

My family doctor Another nominated doctor The ASISA call centre

Eng Afr Contact telephone number

Time of day to contact you

In terms of the Income Tax Act (Act 58 of 1962 and RF 1/2011) lump sum benefi ts are exempt from lump sum tax upon withdrawal/resignation/liquidation:

– if they originate from an approved pension fund and are transferred to another approved pension fund/preservation pension fund/retirement annuity fund; or

– if they originate from an approved provident fund and are transferred to another approved pension fund/preservation provident fund/provident fund/

retirement annuity fund.

NB: 1. This form is used only in the case of the above-mentioned types of transfers and only if the member’s membership of the transfer-

ring fund has been terminated. It is therefore not used if the receiving fund is not an approved fund and likewise if the member’s

benefi t is used to purchase an optional life annuity; it is also not used if the transferring fund purchases a life annuity only and the

member’s membership is not terminated.

2. The registered names of the transferring and receiving funds must be used.

1. General

Acknowledgement of transfers between approved funds (Applicable to Sanlam Cumulus Pension/Provident Preserver)

2.1 Full names and surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.2 Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3 Date of birth (DDMMCCYY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2.4 Income tax reference no. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 Revenue Offi ce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2. Particulars of member

3. Statement on behalf of transferring fund

4. Statement on behalf of the receiving fund

I, the undersigned, declare on behalf of (delete that which is not applicable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (registered name of Fund)

4.1 that the receiving Fund is an approved preservation pension fund/preservation provident fund/retirement annuity fund (delete that which is not applicable);

4.2 that R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has been received for application under the receiving Fund on behalf of the member; and

4.3 that the transfer took place in accordance with the provisions of the Act and RF 1/2011 as defi ned in General above.

Signed at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on this . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Provident Fund

Sanlam Preservation Pension Fund / Sanlam Preservation

Offi cial stamp of Insurer/

fund receiving the benefi t

Plan number(s)

I, the undersigned, declare on behalf of the . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (registered name of Fund)

3.1 that the transferring Fund is an approved pension fund/provident fund (delete that which is not applicable); and

3.2 that the member enjoyed membership of the transferring fund from . . . . . . / . . . . . . / . . . . . . . . . . . . . . until . . . . . . / . . . . . . / . . . . . . . . . . . . .

3.3 The total amount released for transfer: R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Portion originating from the amount in 3.3, which is available as a retirement benefi t only: R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.5 Portion originating from the amount in 3.3, (3.3 less 3.4) to which no restrictions or conditions apply i.r.o. the benefi t being transferred: R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.6 If provident fund, member’s own contributions to the fund: R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3.7 Reason for exit: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signed at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . on this . . . . . . . . . . . . day of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Signature of authorised person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (On behalf of transferring fund.)

Offi cial stamp of

transferring fund

NAME AND SURNAME OF POLICYHOLDER ______________________________________________________________________

IDENTITY/REGISTRATION NUMBER OF POLICYHOLDER _________________________________________________________

NAME AND SURNAME OF REPRESENTATIVE ____________________________________________________________________

FULL NAME OF FSP (Brokerage or insurer) ______________________________________________________________________

NEW POLICY

REPLACEMENT POLICY ADVICE RECORD

To be completed in consultation with your representative

Please note that this does not serve as a cancellation of the replaced policy; you must advise the insurer in writing about cancellation of a policy.

Type of policy: Investment or risk Policy/Proposal number Insurer

POLICY BEING REPLACED

Type of policy: Investment or risk Policy/Proposal number Insurer

QUESTION TO THE REPRESENTATIVETo be discussed with policyholder and answered in any event

Does this proposal constitute replacement of an investment policy with a recurring premium investment or risk policy that will lead to or has led to the levying/deduction of a termination charge (causal event charges and administration charges) of more than 15% of the replaced policy’s fund value? Refer to the defi nitions in Part 3 of the Regulations to the Long-Term Insurance Act, 1998 (commission regulations).

Yes No

1. REASONS WHY REPLACEMENT MAY NOT BE ADVISABLE

If you do replace any policy, we want to ensure that you make an informed choice. Please read the following information, carefully and discuss with your representative.

• You will pay some charges and fees twice (e.g. commission, underwriting expenses & other initial charges levied by the insurer) – initially on the existing policy and once again on the new policy.

• You may pay higher premiums for risk (or a bigger part of the premium) on the new policy because you are older now or your health situation might have changed.

• Your new policy may not have the same life cover or premium guarantees as the existing policy. Check the period for which the life cover or other cover amounts are guaranteed before the insurer is entitled to change your premiums or reduce or remove cover.

• Your new policy may not have the same investment performance guarantees as the existing policy (if applicable).

• Your new policy may have more exclusions, restrictions or waiting periods particularly if your health has deteriorated.

• The amount of money that you can withdraw under the new policy may be less (if applicable). A new policy will usually have legal restrictions on access within the fi rst 5 years.

• You may lose the tax advantage of your existing policy (if applicable).

• The surrender value or paid up value of your existing policy may be as low as 65% of the policy value before the change, and could be even less than premiums paid in since unrecovered initial expenses must fi rst be deducted. Check what charges you will be paying on termination of the old policy and see whether the advantages of the old policy will make up for any such charges.

• The investment risk under the new policy may be higher. Remember that the past performance of a fund or asset manager of a fund is not necessarliy an indication of future performance.

2. REASONS FOR THE CHANGE OF POLICY/POLICIES Not required if replacement policy effected as a result of the internet, telephone or direct marketing

2.1 Did you establish whether the existing / terminated policy could be amended to provide similar benefi ts to the replacement policy? (Please print clearly)

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

2.2 If such amendment is / was possible, why do you regard it as appropriate that the terminated policy be replaced by the replacement policy? (Please print clearly)

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

3. TO BE COMPLETED IF THE NEW BUSINESS WAS EFFECTED VIA ELECTRONIC BUSINESS Was the replacement policy effected as a result of the:

Internet Telephone Direct marketing

3.1 Please indicate the date, time of the phone call/negotiation and (if applicable) reference number:

Date _______________________ Time _______________________ Reference ____________________________________

3.2 There may be more factors regarding replacements that could infl uence your decision.

Do you require any further advice?

Yes No

4. DECLARATION Signatures compulsory unless the replacement policy was effected as a result of the internet, telephone or direct marketing

REPRESENTATIVE

• I confi rm that I have taken all reasonable steps to confi rm that the information in this Replacement Policy Advice Records (RPAR) is true and correct.

• I confi rm that in pursuance of my advice to the policyholder to replace the policy(ies) mentioned in this RPAR I have fully discharged my duties as set out in section 8 (d) of the General Code of Conduct for Authorised Financial Services Providers and their Representatives (the Code) and have retained a record of such advice as required by section 3 of the said Code.

Signature __________________________________________________________________

Name and surname ______________________________________________________________________________________________

Date _____________________/__________________________/______________________

POLICYHOLDER

I confi rm that the representative has fully explained the consequences of the replacement of the policy(ies) mentioned in this Replacement Policy Advice Record and I understand the consequences of such replacement(s).

Signature __________________________________________________________________

Name and surname ______________________________________________________________________________________________

Date _____________________/__________________________/______________________

Contact telephone number (___________)________________________________________

e-mail address __________________________________________________________________________________________________

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