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15. STATUTORY NOTICE TO LONG-TERM INSURANCE POLICYHOLDERS. DISCLOSURE AND OTHER LEGALREQUIREMENTS. (This notice does not form part of the Insurance Contract)

17. OFFICES

| | | Cape Town Port Elizabeth (041) 451 -0823 North Wharf, 42 Hans Strydom Avenue Foreshore | | 66 Ground Floor, Old Mutual Building Govan Mbeki Avenue, Port Elizabeth |

| Polokwane (015) 291-3358/5862 Bloemfontein (051) 430-1201 | Suite14 Biccard Park, 43 Biccard street | 1st Floor Finbond Building, 6 Elizabeth street | |

| | | Pietermaritzburg (033) 345-5493Heritage House, Ground Floor 222 Jabu Ndlovu Street, Heritage House Pietermaritzburg, 3200 |

how much of the premium will go towards the benefit? to what portfolio will your benefits be linked?

enable you to purchase a new policy or amend

the policy as a replacement policy:

. The summary in terms of section 48 of the Long-term Insurance Act. 1998.

. The contact number and address of the complaints and compliance officers of the insurer. (the insurer may disclose the above information on a generic basis with additional policyholder specific disclosure).

summary contemplated in section 48 of the Long-term

needs and that you feel you have all the information you need before making a decision.

428 - 8000

If NO, Comment

14. TREATING CUSTOMERS FAIRLY (TCF)

16. FOR OFFICE USE ONLY

SCHEME NO. (if applicable)

As a long-term policyholder,

noted in

right to cancel a policy within 30 days after

Insurance Act. 1998, from the insurer. The same applies to certain changes you make to a policy; the insurer is obliged to conform to you whether you have this right and to explain how to exercise it. Please bear in mind that you may not exercise it if you have already claimed under the policy or in the event, which the policy insures youagainst, has already happened. if the policy has an investment component you will carry an investment loss.

Safrican Compliance OfficerEmail:[email protected]:(011) 778 - 8183P.O. Box 616, Johannesburg, 2000

A new framework has been introduced by the Financial Services Board (FSB) called Treating Customers Fairly (TCF). The aim of the framework is to standardize the financial industry in accordance with the way customers are to be treated.

In terms of TCF as a client or potential client you have the right to know that:

1) You are dealing with a company where the fair treatment of customers is central to the company’s culture.2) Products and services marketed and sold in the retail market are designed to your needs and are targeted accordingly.3) You are given clear information and are kept appropriately informed before, during and after the time of contracting.

4) Where you receive advice, the advice is suitable and takes into account your circumstances.5) You are provided with products that perform as the company has led you to expect, and the associated service is both of an acceptable standard and what you have been led to expect.6) You do not face unreasonable post-sale barriers to change product, switch provider, submit a claim or make a complaint.

Where a Principal Member has chosen to increase Ÿ

a benefit amount for an insured person, or when taking up a continuation:

A 6 (six) month waiting period shall apply to their §increased part of the benefit amount only, if the insured person is younger than 74 (seventy-four) years.§ A 12 (twelve) month waiting period shall apply to

the increased part of the benefit amount only, if the insured person is older than 74 (seventy-four) years.lUpon taking up a continuation option, the

increased benefit amount must be taken up within 1 (one) month of withdrawal, retirement or ceasing to be a Principal Member.lDuring the term of the policy, same-terms

r e i n s t a t e m e n t w i l l b e a v a i l a b l e t o t h e policyholder for 3 (three) months, from the date of last premium payment, without requirement to catch-up on the unpaid premiums. No cover will be provided in this period. Safrican will allow this once over the lifetime of the policy.lWhere a policy has been reinstated as per the

above, the grace period will be reset to one-month.

INSURABLE INTERESTPlease note that all persons insured under the policy must be related to the principal member and/or policy payer, and the principal member and/or policy payer must have an insurable interest in all insured persons under the policy.

INTERMEDIARY SERVICESIn cases where an intermediary is involved, up to a maximum of 15% commission will be payable to the intermediary concerned.

SURRENDER VALUESShould you wish to terminate the policy, you will not receive any cash benefit and/or surrender value. You may not use the benefits under this to be ceded or pledged in any way. No loans will be accepted against this Policy.

EXCLUSIONSDivorced spouses at inception of the policy are not covered, unless sufficient insurable interest can be provided to Safrican at inception, which will be evaluated at Safrican’s discretion.

PREMIUM RATE & POLICY TERMS REVIEWSafrican can alter the premium rate payable and the terms and conditions of the policy, at any time. Safrican will grant you, the policyholder 3 (three) months’ notice of the alterations to your policy.

CONFIRMATION OF COVEROnce your application for funeral cover has been approved, you can expect confirmation of cover within 60 days of receipt of your premium.

CANCELLATIONThe policyholder as well as Safrican reserves the right to cancel this policy at any time after giving you the Policyholder, 2 (two) months’ written notice of such intention.

SUMMARY CLAIMS PROCEDUREIn the event of a death, a Claim Notification Form must be requested from a Safrican office and submitted together with the relevant supporting documents to Safrican within 6 (six) months from the date of death. Failure to do so will result in the benefit being forfeited.Documents that must be sub,itted include, but are not limited to:ŸFully completed Claim Notification Form.ŸProof of DeathŸ (Bl-5) Original or faxed certified copy of

computer produced Death Certificate; orŸ (Bl-18) Original or faxed certified copy of

Unabridged Death Certificate; orŸ (Bl-20) Original or faxed certified copy of

Abridged Death Certificate in respect of stillborn (Only 2 stillborn claims will be accepted per family during the term of the Policy) together with supporting medical documents; andŸ (Bl-1663) Original or faxed copy of the

Notification of Death.ŸCertified copy of Principal Member’s Identity

Document if a South African citizen, or certified copy of Principal Member’s Passport if a foreign national.ŸCertified copy of deceased’s Identity Document

if a South African citizen, or certified copy of deceased’s Passport if a foreign national.Ÿ In the event of a claim for a full-tme student, a

letter confirming full-time study from a recognized educational institution, together with the last academic report, must be submitted.ŸFor a disabled child, confirmation of a Disability

Grant, copy of Medical Report or Medical application of the Principal Member, must be submitted.ŸSafrican reserves the right to request further

documentation or Information as it may deem necessary to accurately assess a claim.ŸSafrican will endeavour to settle the claim within

48 hours, provided that all the claim procedure criteria have been met.

Faxed copies must be clearly certified. Our fax line is 011 778 8183.The details of the Commissioner of Oaths with all the relevant details must be clear.

Documentation submitted other than those listed will not be accepted.

Affidavits are not accepted.Posted documents must be sent via registered mail.As a Policyholder, you are entitled to be provided, upon request, with a copy of the Master Policy

the benefit for children older than 14 years does Ÿ

not exceed the maximum benefit limit of R50 000;the benefit for children younger than 14 and older Ÿ

than 6 years does not exceed the maximum benefit limit of R30 000 (or any other limit as specified by the Long-term Insurance Act); andthe benefit for children younger than 6 years does Ÿ

not exceed the maximum benefit limit of R10 000 (or any other limit as specified by the Long-term Insurance Act).Your extended Family members can take out a Ÿ

Safrican policy, or be covered as Extended Family members by other individuals. However, the maximum benefit limit that they can be covered for by Safrican is R60 000 across all Safrican plans.

The Principal Member must be in possession of a Ÿ

current bank account, which allows debit orders. The agreed Premium will be paid monthly at the beginning of each month.A policy commences on the first day of the Ÿ

calender month following the receipt of the first premium by Safrican.You are allowed a one-month grace period once Ÿ

the policy is in force (i.e. first premium has been received). If you do not pay your premium within that month, your funeral cover will cease without further notice. If your policy has been in force for 12 months, you will have a grace period of one month for every year that your policy was in force, with no reduction in the benefit. This grace period is limited for up to a maximum of 6 (six) months. In case of a claim, the claim value will be reduced by the value of the unpaid premiums.No arrear premiums will be accepted other than Ÿ

in the abovementioned instance.Safrican will terminate the policy on the first Ÿ

occurence of the following:

Ÿ Death of a Principal Member;Ÿ The Principal Member ceasing to pay

premiums subject to the grace period;ŸThe policy is terminated.

ŸShould a single member convert to a full family option, a new application form must be completed and the waiting period will apply to all additional dependants.ŸThe benefit amount for an Extended Family

Member may not exceed the benefit amount for a Principal Member.

WAITING PERIODS:The following waiting periods apply:ŸClaims due to accidental death will be paid

immediately provided that the policy has commenced, i.e. the first premium is received by Safrican and the policy is not in arrears.ŸA 6 (six) month waiting period shall apply from

the date the premium is received by Safrican, in respect of a death due to natural causes, for insured persons is younger than 74 (seventy-four) years.ŸA 12 (twelve) month waiting period shall apply

from the date the premium is received by Safrican, in respect of a death due to natural causes, for insured persons older than 74 (seventy-four) years.

BOKAMOSOFUNERAL BENEFIT PLAN

CELL No.

Principal Member R 30,000

Premium Per Month R 95

Premium per Month R 15

TOTAL PREMIUM PAYABLE R

SINGLE & CHILDREN

• The scheme promoter does not have a mandate to provide advice about the insurance products. They may only give you factual information.• Please do not pay any money to the scheme promoter or broker for any services rendered or in respect of any agremeent with Safrican or any other reasons.• The scheme promoter must comply with Safrican’s internal code of conduct and policies which apply to scheme promoters.

SPOUSE

ID NUMBER POLICY COMMENCEMENT DATE

RESIDENTIAL ADDRESS

POSTAL CODE

Signature

POSTAL ADDRESS

PREFERRED MODE OF COMMUNICATION

REGION

SALARY PER MONTH

• I shall keep Safrican informed of any changes in my banking details, contact details and marriage status.

• I understand and agree that subject to the waiting period for death by natural causes (stipulated in the Terms and Conditions),

Safrican will only be at risk once this application is accepted by Safrican and the first premiumhas been received by Safrican.

• I am financially responsible for assistance in respect of any funeral costs for all the dependants as reflected.

• I understand that I may only take up one contract under the Bokamoso Funeral Benefit Plan, either as a new member or as an option to effect a similar policy when ceasing to be a

member of any existing Safrican policy, or on retirement.

• I understand that this product is offered to me on a non-advice basis, and should I need further assistance regarding the policy, I may contact Safrican’s offices at

telephone number: 011 778 8000

• I am aware that when this policy is introduced by a broker or scheme supporter, Safrican may pay a commission to them (which shall be included in the premium).

• I confirm that this application form has not, neither has part thereof, been completed by anyone representing or purporting to represent me as the Principal Member.

• I, the undersigned, confirm that I have read this declaration and understand and accept all the terms thereof.

I understand that Safrican shall process my personal information for purposes of underwriting and administration of my policy. Safrican shall ensure that all processing of my personal information is done in a responsible manner and in compliance with all regulatory requirements. I understand that if I do not give such consent Safrican cannot accept my application.I understand that Safrican can process my personal information for purposes of possible marketing of its products to me. I understand that I do not have to consent to the processing of my personal information for these purposes.

I nominate the above-mentioned person to be the recipient of the benefit under my Policy in case of death. This is the individual who will receive my cash benefit when I die.

I consent that should I not nominate anyone, the benefit will be payable by Safrican under any of the following circumstances:

• the benefit will be payable to any one of my dependants who can prove that they rely on me for funeral and other related expenses.• the benefit will be payable as per the direction under my most recent official will and testament, a copy of which will be submitted to Safrican at claiming stage.• the benefit will be payable as per direction of the Master of the High court, as per the letter of authority, or any such letter, a copy of which will be submitted to Safrican at claim stage.

hereby authorize the Accountant of the Employer of ……………................................................. to deduct from my salary each month the premium of R………….......................applicable for the cover selected with effect from (month)……..........……………..20….......……and monthly thereafter, and pay this amount to Safrican Insurance Company Limited (“Safrican”) from which I have obtained a policy, until such time as I cancel this authorization in writing, or until I substitute it with a new authorization. Should the premium rate I am paying, be adjusted by Safrican as a result of increase in premium rate, I confirm that the adjusted premium rate may be deducted from my salary until such time as I cancel this authorization in writing or until I substitute it with a new authorization. In the event of this deduction being dishonoured, the policy will lapse, subject to the grace period as stipulated under the terms and conditions. No deductions are accepted for arrear or any other premiums. I understand that this signed document is required in the Safrican offices prior to the deduction date; if not, the deduction will only qualify for the following calendar month’s deductions, and will only commence the following month. Please allow for 6 (six) weeks for your policy to be deducted and loaded.

I hereby authorise Safrican Insurance Company Limited (“Safrican”) to commence a debit order withdrawal from my account on unless specified otherwise on day of the 1st of every month, the month and monthly thereafter, with any future possible increase on the product.I understand that the debit order will be run on the date selected; if for whatever reason it is not honoured, policy will lapse subject to the grace period as stipulated under the terms and my conditions. See the definition of a grace period on section 12.I understand that this signed document is required in the Safrican offices 10 (ten) working days prior to the elected deduction date; if not, the deduction will only qualify for the following calendar month’s deductions, and cover will only commence the following month.

Please ensure that the debit order is drawn from your bank account on the date selected. If not deducted on the selected date, please contact our offices immediatelyon 011 778 8000.

Kindly quote your 13-number Identity Number, when making any payments to Safrican Insurance Company Limited, as reference.

FULL FAMILY

MARITAL STATUS MARRIED DIVORCED WIDOWEDSINGLE

3. EXTENDED FAMILY DEPENDANTS/ EXTENDED CHILDREN

six months waiting period

twelve months waiting period

GP FS KZN EC WC NC NW LP MP

R3 000R3 000 - R6 000 R6 000 - R10 000

R10 000

NAME AND SURNAME ID NUMBER / DATE OF BIRTH NAME AND SURNAME ID NUMBER / DATE OF BIRTH

NAME AND SURNAME ID NUMBER / DATE OF BIRTH RELATIONSHIP PREMIUM AMOUNT

The following details are of the scheme promoter or broker who has presented you with this application form.

Optional Extended Family and Extended Children Benefit.

SPOUSE ID NUMBER

1. PERSONAL DETAILS OF PRINCIPAL MEMBER

2. IMMEDIATE FAMILY DEPENDANTS

5. DECLARATION BY APPLICANT

6. CONSENT FOR USE OF PERSONAL INFORMATION

7. BENEFIT CHOICES

8. SCHEME PROMOTER DETAILS

9. BENEFICIARY DETAILS

10. PERSAL DEDUCTION AUTHORISATION

11. DEBIT ORDER AUTHORITY

12. DEFINITION SECTION

13. TERMS AND CONDITIONS

• Safrican will have discretion.

I declare and agree to the following terms and conditions:

ŸŸ I understand that Safrican means Safrican Insurance Company Limited (Registration number 1935/007463/06), a public company with limited liability, duly incorporated and registered

as such in terms of the company laws of the Republic of South Africa. Safrican is registered as an assurer in terms of the Long-Term Insurance Act, 1998, as amended, and is also an

authorised Financial Services Provider in terms of the FAIS Act, as amended, under FSP registration number 15123.

Ÿ I hereby apply for the Bokamoso Funeral Benefit Plan in accordance with the terms and conditions of the policy contract. I agree that I have read and understand the terms, conditions

benefits and costs reflected on this form.

Ÿ The Master Policy Document can be requested from the Safrican offices.

Ÿ I am aware that I must provide Safrican with details of my Common Law Spouse, Illegitimate Children and Stepchildren at the date within 1 (one) month of the respective dependant

becoming eligible for cover, and that failure to submit such information could result in delays or repudiation of a claim.

Ÿ I am aware that I must inform Safrican in writing within 3 (three) months of the date of birth of any eligible children in order that the children may be covered.

Ÿ All the information provided on this form, is true, correct and complete and will form the basis of this policy. I understand that any misrepresentation or false information can lead to the

cancellation of these benefits, in which case all monies paid to Safrican will be forfeited.

Ÿ I understand that I have a 30 (thirty) day cooling-off period from receipt of this policy to examine the Bokamoso Funeral Benefit Plan. Provided no death or claim has taken place in this

period, I may elect to not take up the Plan, and will inform Safrican in writing of my intention to not accept. AII premiums already paid shall be refunded, less the cost of any risk cover.

EXTENDED FAMILY

Dependants between 21-65 years

R 15,000

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

EXTENDED FAMILY

R 15,000

R 20,000

R 15,000

R 7,500

R 3,750

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 30,000

R 20,000

R 15,000

R 7,500

R 3,750

Spouse

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

EXTENDED FAMILY

R 15,000

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

and or tribal marriages, or a relationship between two people of the same gender, or a relationship between two people who have lived together for at least six consecutive months before the date of death of the Spouse.

Eligible Child:means an unmarried child of the Principal Member, younger than age 22 years, extended to age 26 years if still a full-time student at a recognised institution or until the Principal Member ceases to qualify, which ever event occurs first. This does not include part time or correspondence students.Children who are mentally retarded or totally and permanently disabled at age 22 years or younger, who are unable to care for themselves, are covered until death or until the Principal Member ceases to qualify, which ever event occurs first.

Extended Family:means your family members, who are dependent on you, the Principal Member for financial assistance in the event of their death may be covered. These include parents, parents-in-law, uncles, aunts, brothers, sisters, nephews, nieces, grandparents and children of

the Principal Member who are 22 years of age and older. Up to 10 (ten) dependants may be nominated. Dependants may not exceed the maximum entry age of 84 years.

Extended Child:means a child who is 21 years or younger and does not qualify to be a Child but is financially dependent on the Principal Member. Proof of dependency must be provided. Up to 4 (four) Extended Children may be nominated for cover.

Grace Period:means a period of time after the date that your premium was due, where you can still pay your premium without any penalties to your funeral cover policy.

Accident:means any specific event, occurring at an identifiable time and place that is unplanned and unexpected by the person insured, resulting from unforseen and unintentional circumstances, from an external source to the body.

Month:means a full calendar month, calculated from the day in one month to the next correspondence day in the next month.

Safrican will provide you with a cash benefit you have selected based on your premium when you submit a valid death claim of a Principal Member, Spouse and Eligible Children (where applicable), and/or Extended family members and Extended Children, who have been nominated on the application form.You cannot take out a Safrican policy just for your dependants. This option may be taken up in addition to the Basic Funeral Plan.Only in the case of a life changing event, may

changes be made to Extended Family dependants.

SPECIAL CONDITIONSThe Principal Member and Spouse may be covered multiple times under the Bokamoso Funeral Plan. You, your spouse can be covered under the multiple funeral plans. However, the maximum benefit that you will be covered for is R80 000.Eligible Children may be covered multiple times under the Plan, provided that:

CELL No.

SINGLE & CHILDREN

SPOUSE

RESIDENTIAL ADDRESS

POSTAL CODE

Signature

POSTAL ADDRESS

REGION

SALARY PER MONTH

FULL FAMILY

R3 000R3 000 - R6 000 R6 000 - R10 000

R10 000

SPOUSE ID NUMBER

7. BENEFIT CHOICES

EXTENDED FAMILY

R 15,000

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

EXTENDED FAMILY

R 15,000

R 20,000

R 15,000

R 7,500

R 3,750

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 30,000

R 20,000

R 15,000

R 7,500

R 3,750

Spouse

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

EXTENDED FAMILY

R 15,000

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

CELL No.

SINGLE & CHILDREN

SPOUSE

RESIDENTIAL ADDRESS

POSTAL CODE

Signature

POSTAL ADDRESS

REGION

SALARY PER MONTH

FULL FAMILY

R3 000R3 000 - R6 000 R6 000 - R10 000

R10 000

SPOUSE ID NUMBER

7. BENEFIT CHOICES

EXTENDED FAMILY

R 15,000

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

EXTENDED FAMILY

R 15,000

R 20,000

R 15,000

R 7,500

R 3,750

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 30,000

R 20,000

R 15,000

R 7,500

R 3,750

Spouse

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

EXTENDED FAMILY

R 15,000

EXTENDED CHILDREN

Child 14-21 years

Child 6-13 years

Child 1-5 years

Child 0-11 months

Stillborn

R 15,000

R 7,500

R 3,750

R 1,875

17. OFFICES

428 - 8000

If NO, Comment

noted in

17. OFFICES

428 - 8000

If NO, Comment

noted in