APPLICATION FOR ADVANCE PAYMENT - Pretoria Infinity



|Agile Retirement Range |

|Provident/Pension Preserver |

|Retirement Annuity |

|Send completed form to: |

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

|Checklist |

| |Signed “Investment Application Form”. Note: All fields with a * are compulsory for tax purposes. |

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

| |Signed “Own your life Rewards” subscription form (if applicable). Please email to applications@ownyourliferewards.co.za. |

|Natural persons |

| |Clear copy of your bar-coded ID/copy of back and front of the ID smart card/birth certificate (if a minor)/valid passport (if a foreign |

| |national). |

| |Proof of residential address not older than 3 months. |

|Provident/Pension Preserver |

| |All requirements as listed in the Provident/Pension Preserver section. |

|Additional requirements |

| |Debit order: bank account holder’s identity (if third party individual) or registration documents (if legal entity). |

| |Lump sum proof of deposit: deposit slips for direct deposits or bank confirmation for electronic transfers. |

| |Please use the reference number(s) as indicated on the EFT form which will be provided when your financial adviser prepares the relevant |

| |documents to invest your money. Using incorrect references could delay the investment of your money. |

| |Where a once-off debit has been requested, proof of account will be required. |

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

|Our bank account |

|Cheque or cash deposits, electronic transfers should be made into the correct bank account. |

|For Section 14 transfers and Preservers the relevant details will be provided to the transferring fund. |

|RETIREMENT ANNUITY |

|Provided by Liberty Group Limited (“Liberty”) (registration number 1957/002788/06) - an authorised Financial Services Provider |

|Bank |Standard Bank |

|Branch name |Braamfontein | |

|Branch code |00 4805 | |

|Account |Liberty | |

|Account type |Business Current Account | |

|Account number |200 358 286 | |

|Reference number |L00 |

|When will we act on your instruction? |

|If instructions and required documents are received and the money reflects in our bank account: |

|Before 12:30 on a business day, we will start processing on that day. |

|After 12:30 on a business day, we will start processing on the next business day. |

|On a weekend or public holiday, we will start processing on the next business day. |

|INVESTMENT INFORMATION |

| |

|Replacement of investment |

|Replacement of an existing investment | Yes No |

|Important Note: Replacement of any investment may be to the disadvantage of the member. | |

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

|occur immediately or to replace a discontinued investment 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. | |

|Language: | English | Afrikaans | |

| | | | |

| |Signature of member |

|Financial adviser (To be completed by the financial adviser) |

| |

|Replacement of an existing investment |

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

|aware of the possible detrimental consequences of the replacement of an investment. |

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

|The meaning of replacement, |

|That a replacement is potentially prejudicial, |

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

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

| |Personal reference (internal) |      |

| |

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

|      |      |      |      | |

|      |      |      |      | |

| |

|Money/Payment |

|Lump sum investments must be paid into Liberty’s bank account by direct deposit or EFT. Alternatively you may request a once-off debit from your account, |

|limited to R500 000. |

|The bank account for debit order |

|How frequently do you | Monthly | Quarterly | Half annually | Annually |

|want to invest: | | | | |

| | Once-off debit (Please email copy of the completed Investment Application Form to newbusiness@liberty.co.za). |

|When should we start collecting your recurring investment amount? |DD / MM / YYYY | |

|If all the required documents are received less than five days before this date, we may only start collecting your recurring investment amount in the next |

|month. |

|Account holder |      |ID number |      |

|Bank |      |Branch |      |

|Branch code |      |Account number |      |

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

| |

|Liberty may: |

|Check these details with the bank. |

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

| |

|I will notify Liberty of any change to this bank account for this investment. |

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

| | |      | |      |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

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

|Addresses of member/s |

| |

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

|Correspondence |      |

| |      |Postal code |     |

|Residential |      |

| |      |Postal code |     |

|Business |      |

| |      |Postal code |     |

|MEMBER |

| |

|Title |      |Full names |      |Surname |      |

|Date of birth |DD / MM / YYYY | |South African resident | Yes No |

|ID number (passport number if foreign national)* |      |Country of issue |      |

|Contact |Home |      |Work |      |Cell |      |

|details: | | | | | | |

| |Fax |      |Email |      |

|Note: Provision of your email address will result in your investment summary and all future communication about your investment being forwarded to you |

|electronically. |

|Are you a foreign citizen and/or have dual nationality and/or are you resident for tax purposes anywhere other than South Africa? If| Yes No |

|“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. | |

|Country of residence (for tax purposes) |      |Income tax number* |      |

|Are you an asylum seeker? | Yes No |If “Yes”, please provide asylum permit number |      |

| |

|Beneficiary details |

| |

|First name, subsequent initial & surname |ID number |Relationship to member |% Split |

|      |      |      |     % |

|      |      |      |     % |

|      |      |      |     % |

|      |      |      |     % |

|      |      |      |     % |

|      |      |      |     % |

|Please note that Section 37C of the Pension Funds Act applies. Section 37C gives the Board of Management discretion, to be exercised fairly and reasonably,|

|insofar as the distribution of death benefits is concerned. The objective of this section is to ensure that those persons who were dependent on the |

|deceased member are not left destitute after his/her death, irrespective of whether or not the deceased was legally required to maintain them. It is, |

|however, still important to keep your beneficiary nomination up to date, if applicable. |

| |

|PROVIDENT/PENSION PRESERVER |

|This is an application for membership of the Lifestyle Retirement Preserver Pension Fund and/or the Lifestyle Retirement Preserver Provident Fund, who is a|

|policyholder of the fund member policies (the investment), which is underwritten by Liberty Group Limited (registration number 1957/002788/06). |

|Investment details |

| |

|All the specific investment details are contained in your signed investment proposal number |      |, including |

|details such as the selected retirement date and portfolios. This signed investment proposal forms part of this investment application form. |

| |

|Future investments |

| |

|Any future investment amounts will be invested in the portfolios you have selected for your lump sum investment. The advice fee on any such future |

|investments is payable according to the advice fees you have negotiated with your financial adviser. The Additional Investment Instruction form must be |

|completed if you wish to invest in different portfolios. |

|Signature and declaration |

|I confirm that the rules, terms and conditions, as well as all marketing material of the Lifestyle Retirement Preserver Pension Fund and/or the Lifestyle |

|Retirement Preserver Provident Fund (the Fund), as the case may be, have been explained to me, and that I understand the nature of the investment. |

|I accept and bind myself to the registered rules of the Fund and any other rules, which the Board of Management might formulate thereunder. |

|I accept that I may not make more than one withdrawal prior to retirement. If a withdrawal has been made from the transferring fund, no further withdrawal |

|may be made prior to retirement. Any remaining benefits will only be payable to me at retirement, early retirement due to ill health or according to |

|current legislation and the rules of the Fund. |

|I understand the fee structure applicable to the Fund. |

|I confirm that I have received all the information required in terms of the Policyholder Protection Rules and FAIS. I further confirm that I fully |

|understand the investment proposal provided by my financial adviser for this investment and that the investment proposal forms part of this application. |

|I accept all the rules, terms and conditions that form part of this application and declaration. |

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

| | |

| | |

| | |

|Signature of member | |

| |

|Transfer and new business requirements |

| |Signed Recognition of Transfer form from transferring fund. |

| |FOR SECTION 14 TRANSFERS (SECTION B): |

| |Relevant FSB forms depending on transferring fund’s valuation-exemption. |

| |FSB approval certificate – for valuation-exempt funds. |

| |Recognition of Transfer Form from transferring fund (ROT or Form J) to be submitted by transferring fund immediately prior to transfer. |

| |Replacement Policy Advice Record. |

| |FOR GEPF TRANSFERS: |

| |GEPF Declaration Form (found on Standard Forms). |

| |Section A and C to be fully completed, signed and stamped by the GEPF. |

| |OR |

| |Pension Benefits Government Employee Pension Fund Statement as at the date of transfer and stamped by the GEPF (for this option, please ensure that |

| |the selected retirement date is completed in Section C). |

|Section A |To be completed by transferring fund for new business preservers (Do not complete fields where details already exist on the Recognition |

| |of Transfer Form (ROT)) |

|Registered name of transferring fund |      |

|FSB registration number* |      |SARS approval no. |      |

|Type of fund: | Pension | Provident |

|Commencement date of transferring fund |DD / MM / YYYY |Date member withdrew from transferring fund |DD / MM / YYYY |

|Reason for leaving employment |      |e.g. resignation, retrenchment, dismissal, fund winding up |

| |

|Section B |Section 14 transfers (Do not complete fields where details already exist on the Recognition of Transfer Form (ROT)) |

|Type of transferring fund: | Pension Preservation Fund | Provident Preservation Fund |

|Registered name of transferring preservation fund |      |

|FSB registration number* |      |SARS approval number |      |

|Name of transferring insurer |      |

|Contact person |      |Designation |      |

|Telephone number |      |Email |      |

|Postal address |      |Postal code |      |

| |

|Section C |To be completed by transferring fund for new business preservers and Section 14 transfers (Do not complete fields where details already |

| |exist on the Recognition of Transfer Form (ROT)) |

|Please complete the scheme number and member number if transferring from a Liberty Corporate Benefits administered scheme. |

|Scheme number |      |Member number |      |

| |

|Member details |

|Title |      |Full names |      |

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

|ID number* |      |Income tax number* |      |

|Are you an asylum seeker? | Yes No |If “Yes”, please provide asylum permit number |      |

|Particulars of benefits to be transferred |

|Selected retirement date |DD / MM / YYYY |(Note: Selected retirement date for transferring fund) |

|Gross benefit due to member (minimum individual reserve) |R |      |

|Less: any deduction or amounts paid out by transferring fund |R |      |

|e.g. divorce settlement, housing loan, maintenance order, income tax, certain damages claims, transfer to a retirement annuity |

|Reason for deduction |      |

|Net amount of benefit to be transferred (purchase price) |R |      |

|Amount accessible to member before retirement |R |      |

| |

|Member contributions |

|Provident funds: Total of member’s own contributions without interest |R |      |

|Pension funds: Member contributions that exceeded amounts that ranked for |R |      |

|deduction against the Member’s income in terms of the Income Tax Act | | |

|Public sector funds: Total value of member’s pre-1998 contributions |R |      |

|Period of employment in public sector fund: |From |DD / MM / YYYY |to |DD / MM / YYYY |= |    |completed years. |

|The following restrictions or conditions apply in respect of the benefit being transferred (e.g. in terms of the rules of the transferring fund). |

|      |

|I, the undersigned, warrant on behalf of the TRANSFERRING FUND that the above information is correct and that I am duly authorised to sign on behalf of the|

|transferring fund. |

|      | |      |

|Name and surname of authorised person | |Designation |

| | |DD / MM / YYYY | | |

| | | | | |

| | | | | |

| Signature of authorised person Date |

|Stamp |

|RETIREMENT ANNUITY |

|This is an application for membership of the Lifestyle Retirement Annuity Fund, who is a policyholder of the fund member policies (the investment), which |

|is underwritten by Liberty Group Limited (registration number 1957/002788/06). |

|Investment details |

| |

|All the specific investment details are contained in your signed investment proposal number |      |, including |

|details such as the selected retirement date and portfolios. This signed investment proposal forms part of this investment application form. |

|Source of funds: | Bonus | Savings | Inheritance | Salary | Other: |      |

| |

|Future investments |

| |

|Any future investment amounts will be invested in the portfolios you have selected for your recurring investment. If you do not have a recurring |

|investment, the portfolios selected for your lump sum investment will be used. The advice fee on any future investments is payable according to the advice|

|fees you have negotiated with your financial adviser. The Additional Investment Instruction form must be submitted if you wish to invest in different |

|portfolios.  |

|Signature and declaration |

|I confirm that the rules, terms and conditions, as well as all marketing material of the Lifestyle Retirement Annuity (the Fund) have been explained to me,|

|and that I understand the nature of the investment. |

|I accept and bind myself to the registered rules of the Fund and any other rules, which the Board of Management might formulate thereunder. |

|I accept that I may not make a withdrawal prior to retirement, unless specifically legislated. Benefits will only be payable to me at retirement, early |

|retirement due to ill health or according to current legislation and the rules of the Fund. |

|I understand the fee structure applicable to the Fund. |

|I confirm that I have received all the information required in terms of the Policyholder Protection Rules and FAIS. I further confirm that I fully |

|understand the investment proposal provided by my financial adviser for this investment and that the investment proposal forms part of this application. |

|I accept all the rules, terms and conditions that form part of this application and declaration. |

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

| | |

| | |

| | |

|Signature of member | |

|Financial adviser advice fees and declaration |

| |

|ADVICE FEE MANDATE |

|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 |Other investment portfolios | |

|PROVIDENT/PENSION PRESERVER | |

|Initial advice fee on lump sums (0 – 3.42%) |   % |   % | |

|No initial advice fee is paid on transfers from another | | | |

|Provident/Pension Fund Preserver in terms of Section 14 of the| | | |

|Pension Funds Act, 1956. | | | |

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

| |¹    % |²    % | |

| |NB: Up to a maximum of 0.57% |NB: Up to a maximum of 1.14% | |

|RETIREMENT ANNUITY | |

|Initial advice fee on lump sums (0 – 3.42%) |   % |   % | |

|No initial advice fee is paid on transfers from another | | | |

|Retirement Annuity Fund in terms of Section 14 of the Pension | | | |

|Funds Act, 1956. | | | |

|Initial advice fee on recurring investments |   % |   % | |

|(0 – 3.42%) | | | |

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

| |¹    % |²    % | |

| |NB: Up to a maximum of 0.57% |NB: Up to a maximum of 1.14% | |

|** 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. |

|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 Account. |

| |

|Member declaration |

| |

|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 |

|instruct Liberty to change the amount of any ongoing fee or pay any future ongoing fee 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 is a representative of Liberty and |

|moves between divisions within Liberty, provided that the representative is still contracted to Liberty. |

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

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

|I understand that any minimum death benefit or investment performance guarantee (where applicable) will be reduced by the advice 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 advice fee,|

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

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

| | |

| | |

| | |

|Signature of member/natural or legal guardian | |

|(if a minor) | |

| |

|Financial adviser declaration |

| |

|I declare that I complied with the ASISA Standard on Replacement, Policyholder Protection Rules (PPR), FAIS and that I provided the member with a complete |

|quotation.  |

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

| | |

| | |

| | |

|Signature of financial adviser | |

|Investment 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 investment, 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 investment 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 Group |With registered banks |With certain specially| | |

| |for marketing purposes and|for marketing |selected third parties| | |

| |special offers? |purposes and special |for marketing purposes| | |

| | |offers? |only? | | |

|Member/authorised | Yes No | Yes No | Yes No | |DD / MM / YYYY |

|signatory/natural or legal| | | | | |

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

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

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

|different from above) | | | | | |

| |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 propensity 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: |      |

|      |

|Liberty Agile Range of Investment Products - Portfolio list |

| |

|RISK PROFILE |

|Aggressive |

|High Equity |Balanced Equity |Medium Equity |Conservative Equity |Low Equity |

Last updated July 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 investor |      |

|ID number of investor |      |(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 |INVESTOR |

| |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 investor |Record and I understand the consequences of such replacement(s). |

| |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 investor.

|Name |      |Surname |      |Date |      |Signature | |

MANAGER:

|Name |      |Surname |      |Date |      |Signature | |

INVESTOR: 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 |      |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 | |

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