APPLICATION FOR ADVANCE PAYMENT - Guaranteed income annuity

Growth, Builder, Business and

Income Investment Series

|Liberty – an Authorised Financial Services Provider |Registration number 1957/002788/06 |

|Send completed form to: |

|Email: newbusiness@liberty.co.za |Fax: 011 408 4171 |

|Checklist |

| |Signed application form. |

| |Signed “Advice Fee Mandate” (if applicable). |

| |“Client Declaration and Consent” form, signed by policyholder and all lives assured. |

| |Signed “Replacement Policy Advice Record” (if applicable). |

| |Signed “Own your life Rewards” subscription form (if applicable). |

| |If you are a U.S. citizen/national/resident for U.S. tax purposes please complete a “Self-Certification Declaration” form. |

|Natural persons |

| |Clear copy of your bar-coded ID/copy of back and front of the ID smart card or birth certificate (if minor). |

| |Acceptable proof of residential address. |

| |OR |

| |Tick here if your broker has a FICA rating category of 1 or 2, in which case the above FICA requirements do not apply and the one page |

| |“Broker Declaration” must be submitted instead. |

|Legal entities |

| |FICA documentation (refer to Annexure A in the application form). |

|Foreign Business/Nationals |

| |Natural person FICA cover sheet. |

| |Clear copy of valid passport. |

| |Acceptable proof of residential address. |

| |Proof of valid South African bank account. |

| |South African income tax number (if applicable). |

|POLICY INFORMATION |

| |

|Policy details |

|Replacement of an existing policy | Yes No |

|Important Note: Replacement of any insurance may be to the disadvantage of the policyholder. | |

|Is this application to replace the whole or any part of your existing insurance with any insurer (whether replacement is to occur | |

|immediately or to replace an insurance discontinued within the past four months or within the next four months)? | |

|If “Yes”, the financial adviser must discuss and complete the Replacement Policy Advice Record and attach it to this application | |

|form. | |

|Policy language: | English | Afrikaans | |

|Source (If not ordinary): | Replacement | Option | Conversion | |

| |Signature of policyholder |

| |

|Financial adviser details and declaration (This section should be completed by the financial adviser) |

| |

|Replacement of an existing policy (Not required if replacement policy effected as a result of the internet, telephone or direct marketing) |

|I hereby declare that I have requested and recorded the policyholder's responses to the question above with regard to replacement and that the policyholder |

|is fully aware of the possible detrimental consequences of the replacement of an insurance policy. |

|I further declare that, irrespective of the client’s response to this replacement question, I explained the following to the policyholder: |

|The meaning of replacement, |

|That a replacement is potentially prejudicial, |

|The levying/deduction of a termination charge, and |

|That where a replacement is considered, the client is legally entitled to comprehensive information regarding the consequences of replacement. |

| |Personal reference (internal) | |

| |

|Initials and surname |Personal code |% Split |Liberty code |Signature |

| | | | | |

| | | | | |

| |

|Debit order details |

| |

|For all products excluding Offshore Investment Plan, Flexible Investment Plan, Guaranteed Investment Plan with Income (no once off debits) and Compulsory |

|Annuities. |

|Account holder must be the same as the payer life if Disability Premium Waiver benefit or Retrenchment Premium Waiver benefit/s have been selected on the |

|Builder Investment Series. |

|Account type: | Cheque/Current account Savings account Transmission |

| Debit account | Credit account Once off debit (up to R500 000.00) Debit order date |DD / MM / YYYY |

|Name of bank | |

|Branch code | |Branch name | |

|Account number | |

|Initial of account holder | |Surname/Company name | |

|Account holder relationship: | Own Joint 3rd Party |

| |

|Addresses of policyholder |

| |

|To be completed by the financial adviser: Do you confirm that these are the policyholder’s addresses? | Yes No |

|Correspondence | |

| | |Postal code: | |

|Residential | |

| | |Postal code: | |

|Business | |

| | |Postal code: | |

|Please select if the policyholder would prefer the summary policy document/documentation to be received via email? | Yes No |

|If “Yes”, please confirm policyholder’s email address. | |

|LIFE ASSURED |

| |

|First life assured |

| |

|Title | |Full first names | |Gender | M F |

|Surname | | Date of birth |DD / MM / YYYY |

|Maiden name | |Email address | |

|Marital status: | Single Married Divorced Widowed Separated Engaged |Are you a resident of RSA? | Yes No |

|ID/passport number | |Country of issue | |

|Contact no’s: Home | |Work | |Cell | |Fax | |

| |

|Beneficiaries |

| |

|First name, subsequent initials & surname |National ID number |Relationship to policyholder |% Split |

| | | | % |

| | | | % |

| | | | % |

| | | | % |

| | | | % |

| | | | % |

| |

|Your investment |

| |

|Investing to secure a future income: Income Series |

| |

| | |

| |GUARANTEED INCOME ANNUITY| LIFE ANNUITY JOINT LIFE SINGLE LIFE GUARANTEE TERM (0 – 20 yrs) | |

| | |

|Term | |5 – 20 yrs |Reducing to | % |(1% - 99%) on 1st Death Death 1st Annuitant Death 2nd Annuitant |

| | |

|Purchase price |R |Payable: | Monthly in advance | Quarterly in advance | Half-annual in advance |

| | | Annual in advance | Monthly in arrears | |

|Date of commencement |DD / MM / YYYY | |Income escalation rate (0 - 10%) | % |p.a. |

| |

| |

| LIFE ANNUITY WITH INFLATION | JOINT LIFE SINGLE LIFE GUARANTEE TERM (5 or 10 years) | |

|PROTECTION | | |

|(Payable monthly in arrears) | | |

| |Reducing to | % |(0% - 100%) on | 1st Death | Death 1st Annuitant |

| | | Death 2nd Annuitant |

|Date of commencement |DD / MM / YYYY |Purchase price |R | |

| |

| |

|Lump Sum Investments: Growth Investment Series and Flexible Annuity |

| |

| | | | | | | |

| |INVESTMENT PLAN |INVESTMENT PLAN WITH|RETIREMENT ANNUITY |FLEXIBLE ANNUITY |OFFSHORE INVESTMENT |GUARANTEED INVESTMENT|

| | |INCOME |PLAN | |PLAN |PLAN WITH INCOME |

| | | | | | |GUARANTEED INVESTMENT|

| | | | | | |PLAN |

|Retirement age last |N/A |N/A | |N/A |N/A |N/A |

|Phasing in Period |

|2 - 12 Months | | | | | |N/A |

|Phasing in Funds (tick one) |

|STANLIB Money Market Fund | | | | |N/A |N/A |

|Liberty Dollar Money Market | | | | | |N/A |

|Liberty Euro Money Fund | | | | |N/A |N/A |

|Liberty Sterling Money Fund | | | | |N/A |N/A |

| | |

| |INVESTMENT PLAN |

| | |

|Selected |N/A |R |N/A | % |N/A |R |

| | | | |(2.5% – 17.5%) | | |

|Income Escalation Rate |

|(0% - 10%) |N/A | % |N/A |N/A |N/A | % |

|Income Frequency |

|Monthly |N/A | |N/A | |N/A | |

|Quarterly |N/A |N/A |N/A | |N/A |N/A |

|Half-annual |N/A |N/A |N/A | |N/A |N/A |

|Annual |N/A |N/A |N/A | |N/A |N/A |

|Income Mode |

|Arrears |N/A | |N/A | |N/A | |

|(only monthly allowed) | | | | | | |

|Advance |N/A |N/A |N/A | |N/A |N/A |

|Purchase Price |R |R |R |R |R |R |

|Investment portfolios selected |

| |Policy No. 1 |Percentage | |Policy No. 2 |Percentage |

|1. | | % |1. | | % |

|2. | | % |2. | | % |

|3. | | % |3. | | % |

|4. | | % |4. | | % |

|5. | | % |5. | | % |

|6. | | % |6. | | % |

|7. | | % |7. | | % |

| |TOTAL |100% | |TOTAL |100% |

|Flexible Annuity only |

|Income to be drawn from: | All portfolios proportionally. |

| | STANLIB Money Market first (STANLIB Money Market must have been selected as an investment |

| |portfolio). |

|Income Enhancer Benefit |

| Committed percentage | % |1% – 95% (in 1 % increments) |

|Note: |The committed portion is subject to a minimum of R50 000 and maximum of R5 million. |

| |The Income Enhancer Benefit is only available if the client has attained age 55. |

| |If the Income Enhancer Benefit is selected, proof of age must be submitted i.e. copy of ID. |

| |

|Investing regularly: Builder/Business Investment Series |

| |

| |INVESTMENT BUILDER/ EDUCATION BUILDER|INVESTMENT LINKED REPAYMENT OPTION |RETIREMENT ANNUITY |

| | | |BUILDER |

| | SINGLE RECURRING | SINGLE RECURRING | SINGLE RECURRING |

|Date of commencement |DD /MM /YYYY |DD /MM /YYYY |DD /MM /YYYY |

|Term |N/A | 5 to 15 Years |Retirement age last |

| | | |(min. retirement age = 55) |

|Automatic Premium Increase | |

|0% - 20 % p.a. (in 1% intervals) | % | % | % |

|CPI (min. 5% p.a. and max 20% p.a.) | | | |

|Education CPI (only for Education | |N/A |N/A |

|Builder) | | | |

|Phasing in Period | |

|2 - 12 months | | | |

|(Single premium only) | | | |

|Source (Single premium only) |N/A |N/A | Voluntary Compulsory |

| |INVESTMENT BUILDER/ EDUCATION BUILDER|INVESTMENT LINKED REPAYMENT OPTION |RETIREMENT ANNUITY |

| | | |BUILDER |

|Recurring premium frequency | |

|Monthly | | | |

|Quarterly (not applicable for Education | | | |

|Builder) | | | |

|Half-annually (not applicable for | | | |

|Education Builder) | | | |

|Annually | | | |

|Premium amount | |

|Recurring premium |R |R |R |

|Single premium |R |R |R |

|Benefits (For recurring premiums only) |

|Disability Premium Waiver | |N/A | |

|Retrenchment Premium Waiver | |N/A | |

|Cession (ILRO only) | |

|Please refer to Standard forms, Cessions directory, for the compulsory ILRO cession form that will be automatically called for at new business. Case will |

|not issue without receipt of this form. |

|Investment portfolios selected |

| |Policy No. 1 |Percentage | |Policy No. 2 |Percentage |

|1. | | % |1. | | % |

|2. | | % |2. | | % |

|3. | | % |3. | | % |

|4. | | % |4. | | % |

|5. | | % |5. | | % |

|6. | | % |6. | | % |

|7. | | % |7. | | % |

| |TOTAL |100% | |TOTAL |100% |

| |

|Tax details |

|Annuity and income payments are subject to income tax regulations. To enable Liberty to calculate the correct tax rate, please complete the following: |

|Income tax number | |Chosen rate of tax | % |Number of dependants | |

|Tax directive number | |Tax directive start date |DD / MM / YYYY |

|Unless a tax directive is submitted to support a lower rate, Liberty will be obliged to deduct tax at PAYE rates. |

|FOR COMPULSORY PURCHASE ANNUITIES: |

|Purchase monies must be from an approved Pension, Provident or Retirement Annuity Fund. |

|Please specify name of fund | |

| |

|Protecting your policy |

|Only complete this section if you selected either a Disability or Retrenchment Premium Waiver benefit on your regular investment. |

|Occupation details (life assured) |

|Do you travel beyond RSA borders in the course of your duties? | Yes No |

|If “Yes”, please list country/ies | |

|Is there any hazard associated with your occupation, e.g. mining, asbestos, handling of explosives, working at heights etc.? | Yes No |

|If “Yes”, please provide details | |

|Nominated occupation | |Annual taxable income |R |

|Indicate % time spent in all duties: |Admin. | % |Supervisory | % |Manual | % |Travel | % |

|Nature of duties | |

|Occupation details (payer life) |

|Only complete if the payer is different from the life assured. |

|Do you travel beyond RSA borders in the course of your duties? | Yes No |

|If “Yes”, please list country/ies | |

|Is there any hazard associated with your occupation, e.g. mining, asbestos, handling of explosives, working at heights etc.? | Yes No |

|If “Yes”, please provide details | |

|Nominated occupation | |Annual taxable income |R |

|Indicate % time spent in all duties: |Admin. | % |Supervisory | % |Manual | % |Travel | % |

|Nature of duties | |

| |

|Risk related questions |

|Only applicable for Builder Investment Series and if the Disability Premium Waiver benefit has been selected. |

|Do you or the life to be assured for the premium waiver benefit (if different from the policyholder or first life assured), suffer or | Yes No |

|ever suffered, ever been treated or currently being treated for any physical or mental impairments, (other than for the following | |

|medical reasons)? | |

|Abdominal pain fully investigated |Gastric flu |Previous hiatus hernia – surgically removed |

|Abortion due to amniocentesis |Glasses |Previous pregnancy |

|Abruptio placenta |Glomerulonephritis – 1 attack, fully recovered |Previous tonsillectomy |

|Acne |Heartburn |Previous vasectomy |

|Annual executive medical |Hepatitis A (viral) |Prostatitus – one attack |

|Appendectomy |Hiatus hernia treated with medication |Psoriasis |

|Army medicals |HIV home test kit – negative |Routine HIV for blood donation – negative |

|Bronchitis one attack |Hydatiform mole |Routine HIV for pregnancy – negative |

|Childbirth |Hyperthyroidism |Routine/annual gynecological check-up |

|Childhood asthma |Indigestion |Shingles/herpes (zoster) |

|Concussion |Influenza/flu/cold |Short sighted |

|Cosmetic surgery |Insurance HIV – negative |Sinusitis |

|Cystitis – one attack |Jaundice |Spastic colon |

|Dental check-up |Kidney Stones – one attack |Splenectomy |

|Dental Fillings/cappings/braces |Lipoma |Spontaneous pneumothorax |

|Dentist |Long sighted |Sprained ankle/wrist – surgically treated |

|Diverticulitis |Menisectomy |Sterilization |

|Down’s syndrome child |Mumps |To have wart removed/burnt off |

|Duodenal ulcer |Nephritis – one attack |Tonsillitis |

|Eclampsia |Otitis media |Uterine rupture |

|Ectopic pregnancy |Placenta praevia |Vasectomy |

|Employment HIV – negative |Pleurisy |Verucca (wart) |

|Endometriosis |Pneumonia – one attack |Wisdom teeth |

|Fractured/broken bones -no |Pneumothorax as result of trauma | |

|pin insertion |Previous caesarian section | |

|Gallstones | | |

|Have you or the life assured for the premium waiver benefit (if different from the policyholder or first life assured), ever been | Yes No |

|refused cover, offered cover on special term, ever claimed or received compensation for injury, dread disease or disability, other | |

|than from a medical aid? | |

|Have you or the life assured for the premium waiver benefit (if different from the policyholder or first life assured), received or do| Yes No |

|you expect to receive any advice, counseling, treatment or blood tests in connection with AIDS or an AIDS related disorder (other than| |

|negative/non-reactive tests for insurance purposes, employment, home test kits or routine tests for pregnancy or blood donations)? | |

|Answering “Yes”, to any of the questions above will result in the Disability Premium Waiver benefit being declined. |

| |

|Adviser remuneration |

| |

|Recurring premium – Builder/Business Investment series |

| |

| |Investment Builder/Education Builder |Investment Linked |Retirement Annuity Builder |

| | |Repayment Option | |

|Commission term |Term (5 – 15 years) | |5 Years | |5 Years | |

| | |10 Years | |10 Years | |

| | |15 Years | |15 Years | |

| | |Selected policy term | |20 Years | |

| | |The above is to the maximum of the selected |25 Years | |

| | |policy term | | |

| | | |Selected policy term | |

| | | |The above is to the maximum of the |

| | | |selected term or the earlier of the |

| | | |retirement age or age 75 next |

| | | |birthday |

|Commission type (tick one) | |Commission discount |

|0% Upfront & 100% As and When | | |Upfront commission |0% - 100% | % |

|10% Upfront & 90% As and When | | |As and When commission |0% - 100% | % |

|20% Upfront & 80% As and When | | | | | |

|25% Upfront & 75% As and When | | | | | |

|30% Upfront & 70% As and When | | | | | |

|40% Upfront & 60% As and When | | | | | |

|50% Upfront & 50% As and When | | | | | |

|Please refer to page 9 for the Advice Fee Mandate, if applicable. |Income Option Initial commission | % |(0% to 1.5%) |

| Ongoing commission | 0.25% p.a. | 0.5% p.a. | |

| |

|Income Series (excluding Flexible Annuity and Guaranteed Income Annuity) |

|Commission discount | % |(0% to 100%) |

| |

|Retirement Annuity Plan |

|Initial commission | % |(0% to 2.5% (voluntary) or 1.5% (compulsory)) |

| |

|Flexible Annuity |

|Initial commission | % | (0% to 1.5%) |(Please complete the Advice Fee Mandate at the end of this application) |

| Ongoing advisory fee | 0.285% p.a. | 0.570% p.a. | 0.855% p.a. | 1.140% p.a. | |

| |

|Guaranteed Investment Plan |

|Commission discount | % |(0% to 100%) |

| |

|Retirement Annuity Builder |

|Initial commission | % |(0% to 2.5% (voluntary) or 1.5% (compulsory)) |

| |

|Investment Builder/Investment Linked Repayment Option – Single Premium Portion |

| Initial advisory fee | % |(0% to 5%) |

| |

|OTHER ROLES |

| |

|Policyholder details |

| |

|Title | |First names | |

|Surname/Fund/Company/Trust Name/CC | |Gender | M F |

|Company registration/ID number | |Marital status | |

|Passport number | |Country of issue | |

|Email address | |Date of birth |DD / MM / YYYY |

|Contact numbers: Home | | |Work | |

| | | |Fax | |

|Cell | | | | |

|Are you currently insolvent? | Yes No |If “Yes”, please complete the “Insolvency Trustee Statement”. |

|Are you a resident of RSA? | Yes No | |

|Individuals only: Are you a foreign citizen and/or have dual nationality and/or are you resident for tax purposes anywhere other than| Yes No |

|South Africa? If “Yes”, and you are a U.S. citizen/national/resident for tax purposes in the U.S. please complete the | |

|“Self-Certification Declaration for an Individual” form. | |

|Entities only: Is the entity organised, incorporated or resident for tax purposes outside of South Africa and/or does a foreign | Yes No |

|person/ entity have an equity interest in or exercise control over the entity? If “Yes”, please complete the “Self-Certification | |

|Declaration for an Entity” form. | |

|Tax status of policyholder: | Tax-exempt body | Company/Close corporation | Tax paying trust |

| | Non-tax paying trust | Tax paying body | Natural person |

|Income tax reference number | |Tax office | |

|Income category: | R0 R1 – R4 999 R5 000 – R7 999 R8 000 – R13 999 R14 000 – R29 999 R30 000+ |

|Source of income | |Source of funds for this investment | |

|Other lives assured |

| |

|JOINT LIFE (Only applicable for Investment Plan and Investment Builder) |

|PAYER’S LIFE (Only applicable for Builder Investment Series if the Disability Premium Waiver or Retrenchment Premium Waiver has been selected on the |

|Investment Builder/Education Builder) |

|SECOND ANNUITANT (Only applicable for Joint Life Annuity/Life Annuity with Inflation Protection) |

| |

|Second life assured/second annuitant |

|Title | |Full first names | |Gender | M F |

|Surname | | Date of birth |DD / MM / YYYY |

|Maiden name | |Email address | |

|Marital status: | Single Married Divorced Widowed Separated Engaged |Are you a resident of RSA? | Yes No |

|ID/passport number | |Country of issue | |

|Contact no’s: Home | |Work | |Cell | |Fax | |

|Your relationship to the policyholder other than spouse | |

| |

|Third life assured |

|Title | |Full first names | |Gender | M F |

|Surname | | Date of birth |DD / MM / YYYY |

|Maiden name | |Email address | |

|Marital status: | Single Married Divorced Widowed Separated Engaged |Are you a resident of RSA? | Yes No |

|ID/passport number | |Country of issue | |

|Contact no’s: Home | |Work | |Cell | |Fax | |

|Your relationship to the policyholder other than spouse | |

| |

|Fourth life assured |

|Title | |Full first names | |Gender | M F |

|Surname | | Date of birth |DD / MM / YYYY |

|Maiden name | |Email address | |

|Marital status: | Single Married Divorced Widowed Separated Engaged |Are you a resident of RSA? | Yes No |

|ID/passport number | |Country of issue | |

|Contact no’s: Home | |Work | |Cell | |Fax | |

|Your relationship to the policyholder other than spouse | |

| |

|Fifth life assured |

|Title | |Full first names | |Gender | M F |

|Surname | | Date of birth |DD / MM / YYYY |

|Maiden name | |Email address | |

|Marital status: | Single Married Divorced Widowed Separated Engaged |Are you a resident of RSA? | Yes No |

|ID/passport number | |Country of issue | |

|Contact no’s: Home | |Work | |Cell | |Fax | |

|Your relationship to the policyholder other than spouse | |

| |

|Signatures |

|Signed at | |on |DD / MM / YYYY |

| | | |

| | | |

|Policyholder/Authorised signatory/Natural or | |Signature of additional/Co-owner |

|legal guardian (if a minor) | | |

| | | |

| | | |

|Signature of first life assured (if different from policyholder) | |Signature of second life assured/Second annuitant |

| | | |

| | | |

|Signature of third life assured | |Signature of fourth life assured |

| | | |

| | | |

|Signature of fifth life assured | |Signature of payer life/Account holder |

| | |(if different from policyholder) |

|Applies only to Growth, Builder and Business Investment Series, Flexible Annuities, |

|Agile Retirement Annuities and Preservers and the Liberty Evolve Range of Investments |

|We are required to share, collect and process your Personal Information (PI). Your PI is collected and processed by our staff, representatives or |

|sub-contractors and we make every effort to protect and secure your PI. You are entitled at any time to request access to the information Liberty has |

|collected, processed and shared. |

| |

|PLEASE UPLOAD REQUEST ON BPO AND SEND THIS COMPLETED FORM TO LIBERTY: |

|Please tick the appropriate box: |

| New Business and servicing policies: |Fax: 011 408 4171 OR |Email: newbusiness@liberty.co.za |

| Additional contributions into |Fax: 011 408 2767 OR |Email: opspcd@liberty.co.za |

|existing policies (ADHOCS): | | |

|General detailsint or Change Fiaianncial Adviser (to be completed in all instances) |

|Investment/policy number | |

|Policyholder/Annuitant/Member/Investor (full names) | |

| |

|Financial adviser details (to be completed in all instances) |

|Financial adviser name | |Brokerage (if applicable) | |

|Financial adviser Liberty 13 digit code | |

| |

|Investment advisory fee |

|You have negotiated the following fees with your financial adviser. You hereby authorise Liberty to deduct or facilitate the deduction and payment of the |

|following amounts to your financial adviser for advice and other distribution related charges (where applicable). By making your selection below, you agree to |

|pay the fees at the selected levels for this and all future transactions, until otherwise specified. |

|Type of advice fee* |Exact Income Fund (only |Other investment |

| |applicable to Agile |portfolios |

| |Retirement Range) | |

|INITIAL ADVICE FEE |

|Initial advice fee on lump sums (0 – 5.70%) | % | | % | |

|The initial advice fee is a once off fee deducted from the initial investment amount at the start of | | | | |

|your policy/investment or from any additional ad hoc investments or from the investment value at the | | | | |

|date of extension of your investment/policy. | | | | |

|No initial advice fee is paid on transfers between Retirement Annuity Funds or between Preserver Funds | | | | |

|in terms of Section 14 of the Pension Funds Act, 1956. | | | | |

|Initial advice fee on Agile recurring investments (0 – 3.42%) | % | | % | |

|ONGOING ADVICE FEES |

|Ongoing advice fees (0 – 1.14% per annum) | % |1 | % |² |

|This is not applicable to Legacy, Delta Series and Multiple Choice Living Annuities) |NB: Up to a | |NB: Up to a maximum of| |

|BUT can be added at any time for single premium/lump sum Retirement Annuities, Preservers, |maximum of 0.57% | |1.14% | |

|Multiple-Access Investment Plans and Flexible Annuities but can only be added at or after the 5th | | | | |

|policy/investment anniversary for all endowments and regular premium/recurring investment Retirement | | | | |

|Annuities, except Agile and Evolve where it can be added anytime. | | | | |

|1. Ongoing advice fees are calculated as a percentage of your investment amount. The amount received as the ongoing advice fee will increase at a specified |

|rate every year. |

|2. Ongoing advice fees will be deducted monthly from your Investment value |

|* If these fees are payable to a VAT Vendor, VAT at a rate of 14% will be payable and this will form part of the selected percentage. |

|In addition, please note the following: |

|For Flexible Annuities, the ongoing advice fee will be deducted from the annuitant’s annuity after employees’ income tax has been deducted. The ongoing advice |

|fee is calculated as the selected percentage of the investment value on each policy/investment anniversary and paid in equal instalments to the financial |

|adviser when the annuity is paid to the policyholder/annuitant/member/investor. |

|If the policy/investment is a Retirement Annuity or Preserver, this mandate gives the Fund the authority to instruct Liberty to reduce the fund member |

|policy/investment by the value of the fee. |

|Declaration (to be completed in all instances) |

|I understand that I may at any time instruct Liberty to stop deducting or facilitating the payment of any future ongoing advice fee, or I may at any time |

|(except for Flexible Annuities where this is only allowed at policy anniversary) instruct Liberty to change the amount of any ongoing fee or pay any future |

|ongoing fee to Liberty or to another financial adviser. |

|I understand that any ongoing advice fees agreed to in this mandate may continue to be paid where the financial adviser moves between distribution channels or |

|authorised financial services providers, provided that the financial adviser/authorised financial services provider is contracted with Liberty. |

|I agree that this mandate will be automatically renewed on an annual basis unless I instruct Liberty to cancel it. |

|I understand that on Flexible Annuity policies, the ongoing advice fee will be paid from the annuity (after any employees’ tax is deducted) that is paid from |

|the policy. |

|I understand that these fees are deducted from the investment value of my policy and will therefore reduce the value of my investment accordingly. |

|I also understand that any minimum death benefit or investment performance guarantee (where applicable) will be reduced by the advisory fees deducted. |

|I understand that my financial adviser may work in a Liberty approved team and therefore any advice fees deducted may be shared with the team. |

|I understand that, if the financial adviser is part of a Liberty approved team and the financial adviser is for any reason unable to receive the advisory fee, |

|then the advice fee will become payable to another financial adviser within that approved team. |

|Signed at | |op |DD / MM / Y Y Y Y |

| | | | |

| | | | |

| | | | |

| |Signature of policyholder/member/annuitant/investor | | |

NB: Please retain the original documentation to serve as proof of the agreement with your client.

|Policy number: | |

| |

|Please complete this form using a black pen once you have read and understood the contents on this form. |

|Please fax/email both pages to one of the following entry points: |

|Fax: +27 (0)11 408 7518 |Email: fais@liberty.co.za |

| |

|This declaration contains the consents, guarantees and undertakings that you the client, (for example a product owner, member, duly authorised representative of|

|product owner, life assured, or payer) agree to. You agree that the information below will apply to all products (and services) whereby you have entered into an|

|agreement with us. Where the words “us” and “we” are used in this document it refers to Liberty Holdings Limited and all of its subsidiaries (Liberty). |

| |

|Definitions as referred to in the Protection of Personal Information Act |

|“Personal Information” includes but is not limited to information relating to: race, gender, marital status, nationality, age, physical or mental health, |

|disability, language, education, identity number, telephone number, email, postal or street address, biometric information and financial, criminal or employment|

|history and as more specifically defined the above Act; and |

|“Process” means any operation or activity, whether automated or not, concerning personal information, including: collection, receipt, recording, organisation, |

|collation, storage, updating or modification, retrieval, alteration, consultation, use, dissemination by means of transmission, distribution or making available|

|in any other form, merging, linking, as well as blocking, degradation, erasure or destruction of information. “Processing” will have a similar meaning. |

| |

|We are required by the Financial Advisory and Intermediary Services Act, the Income Tax Act, Tax Administration Act and the Financial Intelligence Centre Act to|

|process some of your information (including personal information). Without your information we will be unable to start or continue to provide products or |

|services to you. |

| |

|You confirm that you understand the product/service |

|You confirm that you understand the nature of the product/services (provided by Liberty as product/services provider or on behalf of a retirement fund, group |

|scheme, collective investment scheme or medical scheme) and that it meets the identified need and that your financial adviser has explained the relevant rules, |

|terms and conditions, and marketing material. |

|Where applicable you confirm that you understand the meaning of replacement (namely where one product is replaced with another similar product) as well as the |

|fact that a replacement can be potentially prejudicial and that you are legally entitled to comprehensive information regarding the consequences of the |

|replacement. |

|Information on Unpaid or Unclaimed Benefits - It is your responsibility as owner of this product to make sure that Liberty always has up-to-date contact |

|information for you and anyone that can benefit on this contract. Where Liberty becomes aware that there are benefits due to be paid out on the policy, we will |

|always first try to contact you or your beneficiaries at the last address provided to us. If we are not able to contact you at this address, we have to take |

|other reasonable steps to try find the person that is entitled to the policy benefits. In order to do this, we may have to appoint external tracing agents. By |

|signing this application, you agree that Liberty can give the external tracing agents access to personal information in order to be able to do any tracing. It |

|is also important to note that, if we have to appoint tracing agents, a tracing and management fee may be deducted by us from the benefits payable. Note that in|

|certain circumstances, an additional amount may be payable by Liberty in relation to any late payment. |

| |

|You guarantee that you are giving all information correctly |

|Where you provide us with Personal Information of a third party for example a beneficiary nomination, you guarantee that you have the third party’s consent to |

|provide us with their Personal Information. |

| |

|You authorise us, our representatives and our contracted third-party (including foreign) service providers as well as any appointed financial adviser(s) to |

|process and further process your Personal Information. |

|We may be required to collect Personal Information from you or other sources in order to service the product and conduct research. |

|This Personal Information may also be used for any other product proposal. |

|Where your Personal Information (e.g. contact details) that we have on record is incorrect, we will take reasonable steps to obtain the correct details. |

|To further process information through the Financial Services Exchange (Pty) Ltd, trading as Astute, and through such registers and databases maintained by or |

|on behalf of the Association for Savings and Investment SA, as well as other insurers in order to save costs and combat fraud. |

| |

|We undertake to only process Personal Information as permitted by law. Where we, or third parties on our behalf, process your Personal Information, we ensure |

|that it remains confidential, secure and will only be kept for as long as required or prescribed. |

| |

|Please note: |

|This authorisation and undertaking extends beyond your death. |

|It applies only for the purposes above and therefore may partially limit your right to privacy. |

|You are entitled at any time to request access to, update or rectify your Personal Information we process. |

|We may at certain times send you relevant information about our products and services. |

|You have the right to be notified when your Personal Information has been compromised. |

|If you provided us with an email address, we will correspond with you via email. |

|In your application for a product you may have provided us with your banking details. |

|By doing so you confirm and authorise us to draw payments, by means of a debit order, against your nominated account. All such withdrawals shall be treated as |

|if you have signed them personally. You agree to pay any banking charges relating to this debit order instruction. You may amend or cancel this authority by |

|giving us 30 days’ notice. If the bank account details are changed at any time, you undertake to notify us of such change and warrant that you will have the |

|necessary authority to do so. |

| |

|All relevant parties must please initial the first page and then sign below where applicable. Your signature below is a confirmation that you have read and |

|understood the “Client Declaration and Consent”. |

| |

|Please complete all details below for your applicable role: |

|Role |Liberty can share your Personal Information: |Signature |Date |

| |Within the Liberty |With registered banks |With certain specially| | |

| |Group for marketing |for marketing |selected third parties| | |

| |purposes and special |purposes and special |for marketing purposes| | |

| |offers? |offers? |only? | | |

|Policyholder/Authorised | Yes No | Yes No | Yes No | |DD / MM / YYYY |

|signatory/Natural or | | | | | |

|legal guardian (if a minor) | | | | | |

| |Full name | |ID/Registration no | |

|Additional/Co-owner | Yes No | Yes No | Yes No | |DD / MM / YYYY |

| |Full name | |ID/Registration no | |

|First life assured (if | Yes No | Yes No | Yes No | |DD / MM / YYYY |

|different from policyholder) | | | | | |

| |Full name | |ID/Registration no | |

|Second life assured/Second | Yes No | Yes No | Yes No | |DD / MM / YYYY |

|annuitant | | | | | |

| |Full name | |ID/Registration no | |

|Third life assured | Yes No | Yes No | Yes No | |DD / MM / YYYY |

| |Full name | |ID/Registration no | |

|Fourth life assured | Yes No | Yes No | Yes No | |DD / MM / YYYY |

| |Full name | |ID/Registration no | |

|Fifth life assured | Yes No | Yes No | Yes No | |DD / MM / YYYY |

| |Full name | |ID/Registration no | |

|Payer life/Account holder (if | Yes No | Yes No | Yes No | |DD / MM / YYYY |

|different from policyholder) | | | | | |

| |Full name | |ID/Registration no | |

| |

|If you in the future change your mind about any of the above please notify Liberty through your financial advisor or directly at 0860456 789 or |

|opspcd@liberty.co.za. |

Do not sign blank or incomplete application forms. In order to avoid any claim being repudiated due to “Non-Disclosure” it is vital that all risks (medical, financial, occupation, hobbies, or legal) are fully disclosed to ensure full underwriting assessment, so the appropriate decision on your application can be made. Please note that in the event of any modification of this form Liberty will regard this application as being invalid.

|What does the Risk Analyser do? |

|The aim of this Risk Analyser is to help the financial adviser and client to determine which risk profile the client may be categorised under and does not |

|constitute advice by Liberty. |

| |

|Please answer the following questions: |

|1. |My current age is: |

| |a. | Under 31 |b. | 31 to 40 |e. | Over 60 |

| |c. | 41 to 50 |d. | 51 to 60 |

| |

|2. |The current value of my savings/capital (including equity in property, share, RA’s. provident funds etc.) is equal to: |

| |a. | Less than half my current (or last earned) annual income |b. | Half of my annual income (salary), pension, interest, etc. |

| |c. | The amount of my gross income in one year |d. | Double my current (or last earned) annual income |

| |e. | Three times my current (or last earned) annual income |f. | Five times my current (or last earned) annual income |

| |

|3. |Within the next few years I expect my income to: |

| |a. | Decline in real terms |b. | Stay about the same (gains equal to inflation) |

| |c. | Increase gradually (slightly faster than inflation) |d. | Increase dramatically (much faster than inflation) |

| |e. | Fluctuate and be unpredictable (Select this option if you only have investment income) |

| |

|4. |Based on my lifestyle and medical history, I expect my risk of serious health problems over the next 10 years to be: |

| |a. | Above average |b. | Average |

| |c. | Low |d. | Almost nil |

| |

|5. |Regarding dependants (minor or adult) and other major costs that I need to incur before retirement: |

| |a. | I will be able to meet all expenses for dependants (including education) and other costs out of my income. |

| |b. | I will have to withdraw a small portion of my savings to pay for dependants and other costs. |

| |c. | I will have to withdraw more than half of my savings to pay for dependants and other costs. |

| |d. | I expect that paying for dependants and other costs will leave me with very little savings when I retire. |

| |e. | I don’t have dependants or major costs to worry about. |

| |

|6. |My investment experience is best described as follows: |

| |a. | I have never invested in equities, either directly or through unit trusts and do not understand these things. |

| |b. | I’ve invested a small amount of money in equities or unit trusts and/or I know what these things are. |

| |c. | I’ve invested a fair amount of money in equities or unit trusts and/or have a good understanding of equities. |

| |d. | I’ve invested in commodities, options and international shares and/or am very knowledgeable about investment |

| |e. | I have a company retirement plan and/or other investments, but I’m not sure exactly where I’m invested and/or I don’t fully |

| | |understand the different asset classes. |

| |

|7. |I plan to start withdrawing money from my savings in: |

| |a. | Less than five years |b. | Five to ten years |

| |c. | Eleven to fifteen years |d. | More than fifteen years |

| |e. | I am already using my savings |

| |

|8. |How do/would you react to fluctuations in the market? |

| |a. | I am (or would be) very concerned if my investments lose value and am (or would be) inclined to sell immediately. |

| |b. | If an investment loses 5% over a quarter, I am (or would be) likely to sell and invest elsewhere. |

| |c. | I wait (or would wait) until I have watched the performance of an investment for at least a year before making changes. |

| |d. | Even if poor market conditions result in significant losses over several years, I will try and stick to a consistent long-term investment |

| | |plan. |

| |

|9. |You invest R100 000 for ten years. Given the best and worst case scenario below, which investment option would you choose? (NB: Not that the best and |

| |worst case scenario are equally profitable.) |

| |a. | Best case outcome:R500 000 - Worst case outcome: R50 000 |b. | Best case outcome: R850 000 - Worst case outcome: R20 000 |

| |c. | Best case outcome:R300 000 - Worst case outcome: R65 000 |d. | Best case outcome: R150 000 - Worst case outcome: R100 000 |

| |

|10. |When I buy car insurance I: |

| |a. | Choose the lowest excess to ensure maximum cover even though my contract costs more. |

| |b. | Choose a moderate level of excess in order to reduce the contribution. |

| |c. | Choose a high excess in order to pay a low premium even though losses may not be covered. |

| |d. | Choose to carry no insurance. |

| |

|Scoring of Questions |

| |

|Please give yourself the following scores depending on the answers you gave, and then add up your scores. |

| |

|Question |a |b |c |d |e |f |Your score |Total Score |

|Investment Portfolio guide |

|Depending on your score obtained above, your tendency for risk falls into one of the following categories: |

|Score |Risk Profile |NOTE |

|0 - 25 |Conservative |You have been made aware that |

| |Conservative investors are investors who want stability and are more concerned with protecting their current |due to the restrictions imposed|

| |investments than increasing the real value of their investments. |by Regulation 28 of the Pension|

| | |Funds Act, you are unable to |

| | |select certain portfolio |

| | |combinations. As a result, you |

| | |acknowledge that, although the |

| | |portfolios chosen are not in |

| | |line with your risk profile, |

| | |they comply with Regulation 28 |

| | |requirements. |

|26 - 45 |Moderately Conservative | |

| |Moderately conservative investors are investors who want to protect their capital and achieve some real | |

| |increase in the value of their investment. | |

|46 - 65 |Moderate | |

| |Moderate investors are long-term investors who want reasonable but relatively stable growth. Some fluctuations| |

| |are tolerable, but investors want less risk than that attributable to a fully equity based investment. | |

|66 - 85 |Moderately Aggressive | |

| |Moderately aggressive investors are long-term investors who want real growth on their capital. A fair amount | |

| |of risk is acceptable. | |

|86 - 100 |Aggressive | |

| |Aggressive investors are long-term investors who want high capital growth. Substantial year-to-year | |

| |fluctuations in value are acceptable in exchange for a potentially high long-term return. | |

|Your derived profile according to risk analyser is: | |Date: |DD / MM / YYYY |

|Name of Liberty financial adviser | | | |

|Name of client | |Signature of client | |

| Agree Disagree |If disagree, state chosen risk profile and the reason for this risk profile: | |

| |

| |

|Growth Investment Series – Portfolio list according to specific risk profile |

| |

|Aggressive |Moderately Aggressive |Moderate |Moderately Conservative |Conservative |

| | | | | |

|■❍ ◆▲ ABSA Select Equity Fund |■❍ ◆▲ Allan Gray Balanced |■❍ ◆▲ ABSA Balanced Fund |■❍ ◆▲ ABSA Absolute Fund |■❍ ◆▲ Allan Gray Stable |

|■❍ ◆▲ Allan Gray Equity |■❍ ◆▲ Excelsior Listed |■❍ ◆▲ Coronation Balanced Plus|■❍ ◆▲ ABSA Inflation |■❍ ◆▲ Excelsior Conservative|

|■❍ ◆▲ Coronation Equity Fund |Property |Fund |Beater Fund |■❍ ▲ Excelsior Conservative |

|■❍ ◆▲ Coronation Top Twenty |■❍ ◆▲ Excelsior Managed |■❍ ◆▲ Coronation Capital Plus |■❍ ◆▲ Coronation Balanced |(C) |

|■❍ ◆▲ Excelsior Aggressive |❍ Excelsior Managed (C |■❍ ◆▲ Coronation House View |Defensive Fund |❍ Excelsior Conservative |

|■❍ ▲ Excelsior Aggressive (C) |Special Offer) |■❍ ◆▲ Excelsior Absolute Plus |▲ Excelsior High Yield |(C Special Offer) |

|■❍ ◆▲ Excelsior Financials |■❍ ▲ Excelsior Managed (C) |Fund |■❍ ◆▲ Excelsior Managed |■❍ ◆▲ Excelsior Income |

|■❍ ◆▲ Excelsior Global Aggressive |■❍ ◆▲ Excelsior Moderately |■❍ ◆▲ Excelsior Aggressive |Cautious |■❍ ◆▲ Excelsior Multi- |

|■❍ ◆▲ Excelsior Global Conservative |Aggressive |Income |■❍ ◆▲ Excelsior Moderately|Manager Absolute Income Fund|

|■❍ ◆▲ Excelsior Global Moderate |■❍ ▲ Excelsior Moderately |■❍ ◆▲ Excelsior Bond |Conservative |■❍ ◆▲ Excelsior Multi- |

|■❍ ◆▲ Excelsior Global Moderately |Aggressive (C) |■❍ ◆▲ Excelsior CPI Plus |■❍ ▲ Excelsior Moderately |Manager Conservative |

|Aggressive |■❍ ◆▲ Excelsior Multi- |■❍ ▲ Excelsior CPI Plus (C) |Conservative(C) |■❍ ▲ Excelsior Multi- Manager|

|■❍ ◆▲ Excelsior Global Moderately |Manager Moderately |❍ Excelsior CPI Plus (C |■❍ ◆▲ Excelsior Multi- |Conservative(C) |

|Conservative |Aggressive |Special Offer) |Manager Moderately |■❍ ◆▲ Excelsior Progressive |

|■❍ ◆▲ Excelsior Index 40 |■❍ ▲ Excelsior Multi- |◆ Excelsior Equity Linked |Conservative |Bonus |

|■❍ ◆▲ Excelsior Industrial |Manager Moderately |Annuity |■❍ ▲ Excelsior Multi- |▲ Investec High Income |

|■❍ ◆▲ Excelsior Multi-Manager |Aggressive(C) |■❍ ◆▲ Excelsior Moderate |Manager Moderately |▲ Noble PP Strategic Income|

|Aggressive |■❍ ◆▲ Excelsior Multi- |■❍ ▲ Excelsior Moderate (C) |Conservative(C) |FoF |

|■❍ ▲ Excelsior Multi-Manager |Manager Property Fund |❍ Excelsior Moderate (C |■❍ ◆▲ Investec Cautious |■❍ ◆▲ STANLIB Money Market|

|Aggressive(C) |■❍ ◆▲ Investec House View |Special Offer) |Managed Fund |Fund |

|■❍ ◆▲ Excelsior Multi-Manager Equity |■❍ ◆▲ Momentum Balanced |■❍ ◆▲ Excelsior Multi-Manager |■❍ ◆▲ Nedgroup | |

|Fund |■❍ ◆▲ Momentum House View |CPI Plus |Investments Stable Fund | |

|■❍ ◆▲ Excelsior Rand Hedge |■❍ ◆▲ Nedgroup Investments |■❍ ▲ Excelsior Multi-Manager |▲ Noble PP Balanced FoF | |

|■❍ ◆▲ Excelsior Resources |Rainmaker Fund |CPI Plus(C) | | |

|■❍ ◆▲ Excelsior Shari’ah Equity |■ ◆▲ Nedgroup |■❍ ◆▲ Excelsior Multi-Manager | | |

|■❍ ◆▲ Excelsior Small Companies |Investments Value Fund |Flexible Property Fund | | |

|■❍ ◆▲ Investec Equity |■❍ ◆▲ Oasis Balanced Fund |■❍ ◆▲ Excelsior Multi-Manager | | |

|■ ◆❑▲ Liberty Euro Money Fund |■❍ ◆▲ Oasis house view |Moderate | | |

|❑ Liberty Offshore Aggressive |■❍ ◆▲ Oasis Crescent Equity |■❍ ▲ Excelsior Multi-Manager | | |

|❑ Liberty Offshore Conservative | |Moderate (C) | | |

|❑ Liberty Offshore Hedge Fund | |■❍ ◆▲ Excelsior Property | | |

|❑ Liberty Offshore Moderate | |■❍ ▲ Excelsior Property (C) | | |

|❑ Liberty Offshore Moderately | |❍ Excelsior Property (C | | |

|Aggressive | |Special Offer) | | |

|❑ Liberty Offshore Moderately | |■❍ ◆▲ Excelsior Shari’ah | | |

|Conservative | |Balanced | | |

|■ ◆❑▲ Liberty Sterling Money Fund | |■❍ ◆▲ Investec Managed | | |

|■ ◆❑▲ Liberty US Dollar Money Fund | |■❍ ◆▲ Nedgroup Investments | | |

|■❍ ◆▲ Momentum Equity | |Managed Fund | | |

|■❍ ◆▲ Old Mutual Albaraka Equity Fund | |▲ Noble PP Wealth Creator | | |

|■❍ ◆▲ STANLIB Equity Fund | |FoF | | |

|■ ◆❑▲ STANLIB Global Bond Fund | |■❍ ◆▲ STANLIB Balanced Fund | | |

|■ ◆❑▲ STANLIB Multi-Manager Global | | | | |

|Equity Fund | | | | |

|■❍ ◆▲ STANLIB Quants Fund | | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | |■ Investment Plan/Investment Plan with Income |

| | | |❑ Offshore Investment Plan |

| | | |❍ Retirement Annuity Plan |

| | | |◆ Flexible Annuity |

| | | |▲ Flexible Investment Plan |

| | | | |

| | | |Please check for and note: |

| | | |● Restrictions and/or availability of portfolios, and |

| | | |● Availability of portfolios on Flexible Annuities for |

| | | |initial |

| | | |considerations of less than R500,000. |

| | | |● The risk rating of the Excelsior Lifetime portfolio is|

| | | |dependent on the client’s years to retirement. |

| | | | |

Last updated July 2015

|Builder/Business Investment Series – Portfolio list according to specific risk profile |

| |

|Aggressive |Moderately Aggressive |Moderate |Moderately Conservative |Conservative |

| | | | | |

|§ ABSA Select Equity Fund |◊ § Allan Gray Balanced |◊ § ABSA Balanced Fund |◊ § ABSA Absolute Fund |◊ § Allan Gray Stable |

|◊ § Allan Gray Equity |◊ § Excelsior Listed |◊ § Coronation Balanced Plus |◊ § ABSA Inflation Beater |◊ § Excelsior Conservative |

|◊ § Coronation Equity Fund |Property |◊ § Coronation Capital Plus |Fund |◊ § Excelsior Conservative |

|◊ § Coronation Top Twenty |◊ § Excelsior Managed |◊ § Coronation House View |◊ § Coronation Balanced |(C) |

|◊ § Excelsior Aggressive |◊ § ø Excelsior Managed© |◊ § Excelsior Absolute Plus |Defensive Fund |◊ § Excelsior Income |

|◊ § Excelsior Financials |◊ § Excelsior Moderately |Fund |◊ § Excelsior Managed |◊ § Excelsior Multi-Manager |

|◊ § Excelsior Global Aggressive |Aggressive |◊ § Excelsior Bond |Cautious |Conservative |

|◊ § Excelsior Global Conservative |◊ § Excelsior Multi-Manager|◊ § Excelsior CPI Plus |◊ § Excelsior Moderately |◊ § Excelsior Multi-Manager |

|◊ § Excelsior Global Moderate |Moderately Aggressive |◊ § ø Excelsior CPI Plus (C) |Conservative |Conservative (C) |

|◊ § Excelsior Global Moderately |◊ § Investec House View |§ Excelsior CPI Plus (C |◊ § Excelsior Moderately |◊ § Excelsior Progressive |

|Aggressive |◊ § Momentum House View |Special Offer) |Conservative (C) |Bonus |

|◊ § Excelsior Global Moderately |◊ § Nedgroup Investments |◊ § Excelsior Moderate |◊ § Excelsior Multi-Manager|◊ § Noble PP Strategic |

|Conservative |Rainmaker |◊ § Excelsior Moderate (C) |Moderately Conservative |Income FoF |

|◊ § Excelsior Index 40 |◊ § Nedgroup Investments |§ Excelsior Moderate (C |◊ § Excelsior Multi-Manager|◊ § STANLIB Money Market |

|◊ § Excelsior Industrial |Value Fund |Special Offer) |Moderately Conservative© |Fund |

|◊ § Excelsior Multi-Manager |◊ § Oasis Crescent Equity |◊ § Excelsior Multi-Manager |◊ § Investec Cautious | |

|Aggressive |◊ § Oasis house view |CPI Plus |Managed Fund | |

|◊ § Excelsior Rand Hedge | |◊ § ø Excelsior Multi-Manager |◊ § Momentum Conservative | |

|◊ § Excelsior Resources | |CPI Plus (C) |Fund | |

|◊ § Excelsior Shari’ah Equity | |◊ § Excelsior Multi-Manager |◊ § Nedgroup Investments | |

|◊ § Excelsior Small Companies | |Moderate |Stable Fund | |

|◊ § Investec Equity | |◊ § Excelsior Multi-Manager |◊ § Noble PP Balanced FoF | |

|◊ § Old Mutual Albaraka Equity Fund| |Moderate (C) | | |

| | |◊ § Excelsior Property | | |

| | |◊ § ø Excelsior Property (C) | | |

| | |◊ § Excelsior Shari’ah | | |

| | |Balanced | | |

| | |◊ § Investec Managed | | |

| | |◊ § Nedgroup Investments | | |

| | |Managed Fund | | |

| | |◊ § Noble PP Wealth Creator | | |

| | |FoF | | |

| | |

| |◊ Investment Builder / Education Builder |

| |§ Retirement Annuity Builder |

| |ø Investment Linked Repayment Option |

| |Note: Please check for restrictions and/or availability of portfolios. |

Last updated February 2015

Disclaimer

The provision and use of this risk analyser does not constitute advice by Liberty. Any legislative, technical or tax information provided is subject to change from time to time. Whilst every attempt has been made to ensure the accuracy of the information and calculations contained herein, no responsibility for any errors that may occur or for any damages suffered as a result of such errors will be accepted by Liberty. The analysis results provided are based on the information provided and should not be relied on in isolation. Any recommendations made must take into account the personal circumstances and specific needs of the client.

|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 the cancellation of a policy. |

|Name and surname of policyholder | |

|ID number of policyholder | |(or registration number in the case of juristic persons) |

|Name and surname of representative | |

|Full name of FSP (Brokerage or Insurer) | |FSP number | |

| |

|New policy: |Type of policy: Investment or risk |Policy or application number |Insurer | |

| | | | | |

| | | | | |

| | | | | |

| |

|Policy being replaced: |Type of policy: Investment or risk |Policy or application number |Insurer | |

| | | | | |

| | | | | |

| | | | | |

| |

|REASONS WHY REPLACEMENT MAY NOT BE ADVISABLE |

|If you do replace any policy, we want to ensure that you make an informed choice. Please mark with an ‘X’ in each block below to indicate that the following |

|information has been carefully discussed with you by 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 have more exclusions, restrictions or waiting periods particularly if your health has deteriorated. | |

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

|The amount of money that you can withdraw under the new policy may be less (if applicable). A new policy will usually have more legal restrictions on | |

|access within the first 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 60% of the policy value before the change, and could even be less than | |

|premiums paid in since unrecovered initial expenses must first be deducted. Check what charges you will be paying on termination of the old policy and | |

|see whether the advantages of the new 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 necessarily an | |

|indication of future performance. | |

|The representative informed you whether the existing/terminated policy could be amended to provide similar benefits to the replacement policy. | |

|If such amendment is/was possible, your representative discussed with you why it is appropriate that the terminated policy be replaced by the | |

|replacement policy. | |

| |

|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 |

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

| |Date: | |Time: | |Reference: | | |

| |

|DECLARATION |

|(Signatures compulsory unless the replacement policy was effected as a result of the internet, telephone or direct marketing.) |

| |REPRESENTATIVE |POLICYHOLDER |

| |I confirm that I have taken all reasonable steps to confirm that the |I confirm that the representative has fully explained the consequences of the|

| |information in this Replacement Policy Advice Records (RPAR) is |replacement of the policy(ies) mentioned in this Replacement Policy Advice |

| |true and correct. I confirm that in pursuance of my advice to the |Record and I understand the consequences of such replacement(s). |

| |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. | |

| | |Contact telephone | | |

| | |number and/or | | |

| | |email address: | | |

| | | | |Signature: | | |

| | | | | | | |

| |Signature: | | | | | |

| |Name: | | |Name: | | |

| |Date: |DD / MM / YYYY | |Date: |DD / MM / YYYY | |

COMPARISON OF POLICY BEING REPLACED WITH NEW POLICY: Please ensure that you fully understand the following comparison of the conditions and benefits of your existing policy and the recommended new policy.

Please initial the items marked*. Your representative must complete all the required information.

|Initial|POLICY DETAILS |EXISTING POLICY/IES |RECOMMENDED NEW POLICY/IES |

|s | | | |

| |Insurance company | | | | |

| |Policy number | | | | |

| |Age of life assured at inception date | | | | |

| |Type of policy (e.g. life cover, investment, pension) | | | | |

| |1. Fees and charges |R |R |R |R |

| |2. Premium (R) (state whether annual, quarterly, |R |R |R |R |

| |monthly or single) | | | | |

| |3. Material difference in the investment risk | | | | |

| |(conservative/moderate/aggressive) | | | | |

| |4. Impact of age or health changes on the premium | | | | |

| |5. Any special terms and conditions | | | | |

| |6. Term/Initial term of policy | | | | |

| |7. Exclusions of liability | | | | |

| |8. Waiting period for claims (months) | | | | |

| * |9. Penalties for cancelling the product (R/%) | | | | |

| * |10. Are the penalties and charges greater than 15% | Yes No |

| |of fund value? | |

| |11. Loadings and excesses (R/%) | | | | |

| |12. Restrictions of benefits | | | | |

| * |13. To what extent are the funds readily realisable? | | | | |

| * |14. Which benefit/cover will be lost or changed? | |R | |R |

| |16. If you were the representative on the old product, | | | | |

| |any incentive, commission received | | | | |

| |17. Tax implications | | | | |

| * |18. Why is the replacement product more suitable to the | |

| |client's needs? | |

REPRESENTATIVE: I declare that this Replacement Policy Advice Record is an accurate and complete record of the advice and recommendations given to the policyholder.

|Name | |Surname | |Date |DD / MM / YYYY |Signature | |

MANAGER:

|Name | |Surname | |Date |DD / MM / YYYY |Signature | |

POLICYHOLDER: I declare that this Replacement Policy Advice Record is an accurate and complete record of the advice and recommendations given to me by the representative. I declare that I have

read and understand the advice given in this Replacement Policy Advice Record. NB: You may, by law, not be requested to sign this form unless it has been fully completed.

|Name | |Surname | |Date |DD / MM / YYYY |Signature | |

|Please complete this form in block letters and email the form and a copy of the member’s ID/front and back copy of the ID smart card, to |

|applications@ownyourliferewards.co.za. |

|Own your life Rewards (Pty) Ltd (Registration Number 1998/009122/07) administers the Own your life Rewards Programme (“Programme”). Own your life Rewards (Pty) |

|Ltd is a separate legal entity from Liberty Holdings Limited, Liberty Group Limited and Liberty Medical Scheme. The Programme is governed by the rules of the |

|Programme and by your signature below, you consent to abide by such rules. For more information, go to ownyourliferewards.co.za. |

|Monthly subscription fees – please choose your subscription type |

| |

|Main member |

|First name | |Surname | |

| R69 |Main member | R115 |Add-On: Fitness Subscription |

| R20 |Add-On: Travel Subscription |Own your life Rewards card number | |

|Email address | |ID/passport no. (copy required) | |

| |

|Additional Subscribers (Spouse/Dependants) |

|Additional subscribers, who are children of the main member, must be over the age of 18 years, but under the age of 21 years. These subscribers may remain on |

|the programme until age 24, subject to submitting proof of study. |

|Relationship to main member | Spouse Dependant |ID/passport no. (copy required) | |

|First name | |Surname | |

|Cell phone number | | |Gender | M F |

|Email address (compulsory) | |Date of birth |DD / MM / YYYY |

| R69 |Per subscriber | R115 |Add-On: Fitness Subscription |

| R20 |Add-On: Travel Subscription |Own your life Rewards card number | |

|Relationship to main member | Dependant |ID/passport no. (copy required) | |

|First name | |Surname | |

|Cell phone number | | |Gender | M F |

|Email address (compulsory) | |Date of birth |DD / MM / YYYY |

| R69 |Per subscriber | R115 |Add-On: Fitness Subscription |

| R20 |Add-On: Travel Subscription |Own your life Rewards card number | |

| |

|The bank account for this debit order |

|On which day of the month should we debit your bank account? |DD | |

|Account holder | |ID/passport number | |

|Bank | |Branch | |

|Branch code | |Account number | |

|Account type | Cheque/Current account Savings account Transmission |

|Own your life Rewards may: |

|Collect money from this bank account for the debit order. |

|Check these details with the bank. |

|I will notify Own your life Rewards of any change to this bank account. I confirm that I can sign for this programme. |

|Signed at | |on |DD / MM / YYYY |

| | | | | |

| | | | | |

| | | | | |

|Authorised signature of account holder | |Name and surname of signatory | |Capacity |

| |

|Your agreement with Own your life Rewards on sharing your information |

|We are required to share, collect and process your Personal Information (PI). Your PI is collected and processed by our staff, representatives or |

|sub-contractors and we make every effort to protect and secure your PI. You are entitled at any time to request access to the information, the Programme has |

|collected, processed and shared. |

| |

|I confirm that the Programme may use my PI to tell me about communication on: |

| Programme Partners and their Products | Own your life Rewards Programme (mandatory) |

|Signed at | |on |DD / MM / YYYY |

| | |

| | |

| | |

| | |

|Signature of main member | |

| | |

|Natural Persons |Close corporations |

| | |

|Copy of national identity document. If identity document is unavailable |CK1. |

|provide a copies of national drivers licence or passport for the investor as |CK2 if applicable or other official documents issued by the Registrar of |

|well the duly authorised representative (e.g. guardian, curator) if |Close Corporations setting out the details of the registered name, number and|

|applicable. |registered address of the Close Corporation. |

|Any one of the following documents (not older than 3 months) are acceptable, |Copy of national identity document, if unavailable provide copies of national|

|provided they reflect the name and residential address of the investor and |drivers licence or passport for: |

|duly authorised representative (if applicable) |All the members of the Close Corporation. |

|Utility bill/rates and taxes |Any other person authorised to represent the Close Corporation (if not listed|

|Bank Statement |above). |

|Rental Agreement |Each natural person, legal entity, trust or partnership with more than 25% |

|Body Corporate or share block association account/levy statement |voting rights. |

|Short Term assurance contract document/schedule |Any one of the following documents (not older than 3 months) reflecting the |

|Telephone/cellular account |name and physical address of the Close Corporation: |

|Valid TV Licence |Utility bill/rates and taxes |

|Recent motor vehicle documentation such as licence renewals and fines |Bank Statement |

|Home Security/armed response accounts |Rental Agreement |

|Large retail accounts e.g. Woolworths, Edgars etc. |Short Term insurance policy document or schedule |

| |Body Corporate account/levy statement |

|Please note that a FICA Standard Form for Natural Persons will have to be | |

|completed as it applies to the investor and duly authorised representative if|Please note that a FICA Standard Form for Close Corporations will also have |

|applicable. Proof of authority in this instance will be required from the |to be completed to capture the name, identity number, address and contact |

|representative as well. |details for the persons identified in point 3 above. |

| | |

|RSA unlisted companies |Trusts |

| | |

|CM1 or COR14.1. |Trust Deed. |

|CM22 or COR 21. |Letter of authority (if registered in South Africa). If the Trust is created |

|CM29 or COR 39 or other official documents issued by the Registrar of |outside of RSA, an official document reflecting same particulars issued by an|

|Companies setting out the details of the registered name, number and |authority in the country where the Trust is created which administers or |

|registered address of the company and directors details. |oversees laws relating to Trusts in that country. |

|Copy of national identity document, if unavailable provide copies of national|Copy of national identity document, if unavailable provide copies of national|

|drivers licence or passport for: |drivers licence or passport for each of the persons listed below: |

|Each natural person authorised to represent the company (attach proof of |Founder |

|authority). |Trustees |

|The manager of the company (e.g. managing director/general manager if not |Beneficiaries named in the Trust Deed. Note that full details and a copy of |

|listed above already). |identity document of each natural person authorised to represent the Trust |

|Each natural person, legal entity trust or partnership with more than 25% |(only if not an appointed Trustee) will be required with proof of the |

|voting rights. |required authority as well. |

|Any one of the following documents (not older than 3 months) reflecting the| |

|name and physical address of the company: |Please note that a FICA Standard Form for Trusts will also have to be |

|Utility bill/rates and taxes |completed to capture the name, identity number, address and contact details |

|Bank Statement |for the persons identified in point 3 above. |

|Rental Agreement | |

|Short Term insurance policy document or schedule | |

|Body Corporate account/levy | |

| | |

|Please note that a FICA Standard Form for Companies will also have to be | |

|completed to capture the name, identity number, address and contact details | |

|for the persons identified in point 4 above. | |

| | |

|Other legal persons |Note: |

| | |

|Official documentation regarding the legal status and members. |A “Confirmation of Residential Address By Co- habitant” FICA Standard Form |

|Proof physical address of entity. |will have to be completed in instances for example where the investor is |

|Copy of national identity document, if unavailable provide copies of national|residing on another person’s property due to lease agreements etc. As a |

|drivers licence or passport for each of the persons listed below: |result proof of address is obtainable from the owner of the property along |

|Each person who is authorised to represent the company (Attach proof of |with the completed co habitant form. |

|authority). |A copy of identity documents for both the owner of the property and investor |

| |will be required as well as proof of address in the name of the property |

|Please note that a FICA Standard Form for Other Entities will also have to be|owner. |

|completed to capture the name, identity number, address and contact details | |

|for the persons identified in point 3 above. |Anyone of the following documents are acceptable provided they reflect the |

| |name and residential address: |

| |Utility bill/rates and taxes |

| |Bank Statement |

| |Rental Agreement |

| |Body Corporate or share block association account/levy statement |

| |Short Term assurance contract document/schedule |

| |Telephone/cellular account |

| |Valid TV Licence |

| |Recent motor vehicle documentation such as licence renewals and fines |

| |Home Security/armed response accounts |

| |Large retail accounts e.g. Woolworths, Edgars etc. |

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