A B C. Postal Address Postal Code. Birth Date: D D M M Y Y Y Y Gender: Benefit % 100%

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1 WISDO financial services (pty) ltd Building C, Oxbow Lane, The Estuaries, Century City, 744 Tel: ax: e-ail: Authorised Representative of SP: 684 Broker Name: Broker Code: / / Union Affiliation Product Applied or A B C D L L2 L3 Insured s Details (Please complete your personal details in BLOCK LETTERS) orename(s): Title: Birth Gender: ale emale Home Address: Postal Address ID Number: Telephone: Cell phone: The number that you provide will be credited with airtime for the REE AIRTIE product. Your Spouse / Partner s Details orename(s): Vodacom TN Cell C Title: Gender: ale emale ID Number: Birth Your Children s Details Initials and Surname Gender Date of Birth Beneficiary orename(s): Title: Birth D Relationship to Insured Benefit % 00% Gender: ale emale Signature: Total Premium: Principal ember premium + Extended amily Premium Payment Authorisation Direct Debit: Accountholder s Surname Name of Bank: Branch Name: R + R = R Initials: Branch Code: Type of Account: Cheque Transmission Savings Account Number: Premium: R I authorise Zwelonke Holdings (Reg. No. 200/006430/07) to debit my account as indicated on the day of each month with the total premium above, inclusive of commission and administration fee. I agree that variations can be made if I am given 30 days written notice of the general increase of the monthly cost. I understand that the withdrawal hereby authorised will be processed by computer system. I agree to pay any bank charges relating to this debit order instruction. This authority may be cancelled by me by giving thirty days notice in writing. I acknowledge that the party hereby authorised to affect the drawing(s) against my account may cede or assign any of its rights to any third party without my prior written consent to the authorised party. I understand that my policy documents will be mailed to me and its full terms, conditions and exclusions will apply. Signature:

2 Application orm Extended amily uneral Cover PLEASE TE: ONLY ONE LEVEL O COVER CAN BE SELECTED. This sum assured will apply to all family members covered on the Extended amily uneral Benefit. The total premium will be deducted from the Principal embers Bank Account as per the Debit Order Instruction. This option can only be chosen if the Principal member is covered through either product A, B, C or D.. Title: 2. Title: 3. Title: 4. Title: 5. Title: 6. Title: Age next Birthday 7. Title: 8. Title: DECLARATION: I declare that to the best of my knowledge and belief the particulars given above are true and correct. I understand and agree that any wilful misstatement in this application will invalidate any claim to benefit under this Policy and I undertake to abide by the terms and conditions of the Policy. AU Insurance shall not be liable for any amount until it has accepted this application, and I agree to the appropriate deductions being made from my bank account: Total Premium for extended family members to be added to my basic premium. R Proposer Signature:

3 uneral Plan A B C D Principal R R R R Spouse R R R R Children 4-2 years (25) R R R R Children 6-3 years R R R R Children -5 years R R R R Stillborn to months R R R R Trauma and Assault Protection 24 Hour Emergency assistance helpline Emergency transport to nearest medical facility Assault cover of R5000 per person. ax R0 000 per family Trauma cover of R5000 per person. ax R0 000 per family HIV Protection Treatment 24 hour access to counsellors 3 Psychiatric consultations per incident 3 HIV Blood tests per incident 30 day starter pack of anti retrovirals 7 day course of STI medication Registration for HIV management program orning after pill in case of rape REE ONTHLY AIRTIE R25 per month N/A N/A N/A Premiums R95.00 per month R5 per month R85 per month R55 per month Once off Admin ee payable with st premium R80.00 R80.00 R80.00 R80.00 Note: * Children covered up to 25 if still studying EXTENDED AILY BENEITS * ONLY AVAILABLE IN CONJUNCTION WITH A, B, C OR D ABOVE. STAND ALONE EXTENDED AILY COVER LEVEL O COVER to 50 years 5 to 75 years Death due to natural Causes: 6 month waiting period Death due to TB and Cancer: 2 onth waiting period Suicide: 24 month waiting period ax age of entry 65 next birthday AGE CATEGORIES R3 300 R0.3 R24.38 Per member per month R7 000 R20.25 R48.75 Per member per month R0 900 R30.38 R73.3 Per member per month ree airtime option: Airtime delivered 0 days after premium collection date Administered by Zwelonke Holdings (Pty) Limited, SP 684 uneral Insurance Underwritten by African Unity Insurance Limited, SP 8447 Product chosen Date Client Signature

4 WISDO Justice on - Call Product Applied or L L2 L3 Insured s Details (Please complete your personal details in BLOCK LETTERS) orename(s): Title: Birth Gender: ale emale Home Address: Postal Address ID Number: Telephone: Cell phone: Underwritten by Western National Insurance Limited, SP 9465 Benefit L L2 L3 Preventative Actions The number of half-hour consultations per matter Contribution towards cost per matter R50.00 R00 Legal costs and Legal advice Benefits / Cover Wills, trusts and ante nuptial contracts per benefit cycle iscellaneous matters per benefit cycle Contractual actions per benefit cycle R Contractual actions extensions Actions against Insurers due to repudiation of a motor claim or refused indemnity under such motor policy, subject to the limits applicable to the policy benefit it attaches to and the aggregate limit on the policy per Benefit Cycle, expressed as a percentage of the cost award, limited to the expressed 50% 00% percentage of the contractual actions benefit. Delictual actions per benefit cycle atrimonial actions per benefit cycle (limited to claim per cycle) Criminal proceedings per benefit cycle Labour atters per benefit cycle Limitations of Policy Benefits for any one Benefit Cycle General Extensions Adverse legal costs awards made against you, subject to the limits applicable to the policy benefits it attaches to and the aggregate limit on the policy per Benefit Cycle, expressed as a percentage of the cost award R R R R R R R R % 50% 00% ONTHLY PREIU R25 R45 R00 Payment Authorisation Direct Debit: Accountholder s Surname Initials: Name of Bank: Branch Code: Branch Name: Type of Account: Cheque Transmission Savings Account Number: Premium: R I authorise Western Insurance Limited to debit my account as indicated on the day of each month with the total premium above, inclusive of commission and administration fee. I agree that variations can be made if I am given 30 days written notice of the general increase of the monthly cost. I understand that the withdrawal hereby authorised will be processed by computer system. I agree to pay any bank charges relating to this debit order instruction. This authority may be cancelled by me by giving thirty days notice in writing. I acknowledge that the party hereby authorised to affect the drawing(s) against my account may cede or assign any of its rights to any third party without my prior written consent to the authorised party. I understand that my policy documents will be mailed to me and its full terms, conditions and exclusions will apply. Signature:

5 Statutory notice to long term and short term insurance policy holders (This notice does not form part of your Insurance contract or any other document) As a member of a long-term or short term insurance policy, or prospective member, you have the right to the following information:. The intermediary (insurance broker or representative) dealing with you must at the earliest reasonable opportunity disclose: a. Name, physical and postal address and telephone number. b. Legal capacity: whether independent or representing an insurer or brokerage. c. Concise details of relevant experience. d. Insurance products that may be sold. e. Insurer whose products may be marketed. f. Indemnity cover held yes/no. g. Shareholdings in insurer, if 0% or more. h. Name of insurers from which intermediary received 30% or more in total commission and remuneration during the past calendar year. (The intermediary must be able to produce proof of contractual relationship with and accreditation by the insurers concerned.) 2. Your right to know the impact of the decision you elect to make: a. The intermediary must inform you of: The premium you will be paying. The nature and extent of the benefits you will receive. b. If the benefits are linked to the performance of certain assets: How much of the premium will go towards the benefit? To what portfolio will your benefits be linked? c. The possible impact of this purchase on your finances: d. The possible impact of this purchase on your other policies (affordability). e. The possible impact of this purchase on your investment portfolio (affordability). f. The flexibility of change you may make to the proposed contract. g. The contract in terms of the product you intend to purchase. (It is very important that you are quite sure that the product or transaction meets with your needs and that you feel you have all the information you need to make a decision.) 3. Your right when being advised to replace an existing policy: You may be advised to cancel a policy to enable you to purchase a new policy or amend an existing policy, unless: a. The intermediary identifies the policy as a replacement policy. b. The implications of cancellation of the policy are disclosed to you, such as: The influence of your benefits under the old policy. The additional costs incurred with the replacement. c. The insurer which issued the original policy will contact you; you are advised to discuss the matter with its representative. The contact number and address of the complaints and compliance officers of the insurer. 5. Your right to cancel the transaction: In most cases, you have a right to cancel a policy in writing within 30 days after receipt of the summary contemplated in Section 48 from the insurer. The same applies to certain changes you may make to a policy. The insurer is obliged to confirm to you whether you have this right and to explain how to exercise it. Please bear in mind that you may not exercise it if you have already claimed under this policy or if the event, which the policy insurers you against, has already happened. If the policy has an investment component, you will carry any investment fees. 6. Premium Breakdown The premium is broken down as follows: Premium Commission ees Total 80% 0% 0% 00% 7. Important warning: It is very important that you are quite sure that the product or transaction meets your needs and that you feel you have all the information you need before making a decision. It is recommended that you discuss with the Intermediary or insurer the possible impact of the proposed transaction on your finances, your other policies or your broader investment portfolio. You should also ask for information about the flexibility of any proposed policy. Where paper forms are required, it is advisable to sign them only once they are fully completed. eel free to make notes regarding verbal information, and to ask for written confirmation or copies of documents. Remember that you may contact either the Long-term Insurance Ombudsman or the Registrar of Long-term Insurance, whose details are set out below if you have any concerns regarding a product sold to you or advice given to you. 8. Particulars of the Long-term Insurance Ombudsman: P.O. Box CLAREONT 7735 Tel: ax: Particulars of Registrar of Long-term Insurance: inancial Services Board P.O. Box ENLO PARK 002 Tel: ax: Particulars of the Short-term Insurance Ombudsman: P.O. Box BRAAONTEIN 207 Tel: ax: Particulars of Registrar of Short-term Insurance: inancial Services Board P.O. Box ENLO PARK 002 Tel: ax: (You may be requested to sign a copy of this document) 4. Your right to be informed by the insurer: You will receive documentation from the insurer confirming policy details as discussed in paragraph 2 of the Notice, which will also include: a. The name of the Insurer b. The product being purchased c. The cost in Rands of the transaction d. In the case of policies with an investment element, the ongoing expense and any other fees or charges payable. You will also receive:the summary in terms of section 48 of the Long-term insurance Act, 988. (The insurer may disclose the above information in a generic basis with additional policyholder specific disclosure.) Name: Address: Cel: Tel: ax: e-ail: Agent Contact Detail

6 Summary of benefits uneral Plan A B C D Principal R R R R Spouse R R R R Children 4-2 years (25) R R R R Children 6-3 years R R R R Children -5 years R R R R Stillborn to months R R R R Trauma and Assault Protection 24 Hour Emergency assistance helpline Emergency transport to nearest medical facility Assault cover of R5000 per person. ax R0 000 per family Trauma cover of R5000 per person. ax R0 000 per family HIV Protection Treatment 24 hour access to counsellors 3 Psychiatric consultations per incident 3 HIV Blood tests per incident 30 day starter pack of anti retrovirals 7 day course of STI medication Registration for HIV management program orning after pill in case of rape REE ONTHLY AIRTIE R25 per month N/A N/A N/A Premiums R95.00 per month R5 per month R85 per month R55 per month Once off Admin ee payable in month R80.00 R80.00 R80.00 R80.00 Note: * Children covered up to 25 if still studying * No waiting periods for Trauma and Assault Protection and HIV protection EXTENDED AILY BENEITS * ONLY AVAILABLE IN CONJUNCTION WITH A, B, C OR D ABOVE. STAND ALONE EXTENDED AILY COVER AGE CATEGORIES LEVEL O COVER to 50 years 5 to 75 years R3 300 R0.3 R24.38 Per member per month R7 000 R20.25 R48.75 Per member per month R0 900 R30.38 R73.3 Per member per month uneral Insurance Underwritten by African Unity Insurance Limited, SP Administered by Zwelonke Holdings (Pty) Limited, SP 684 Waiting Periods: () Natural Causes: 6 months (2) TB and Cancer: 2 onth waiting period (3).Suicide: 24 onths (4) Accidental Death: st premium ax age of entry 65 next birthday Airtime Delivery: 0 days after receipt of premium The number of half-hour consultations per matter Contribution towards cost per matter LEGAL BENEITS L L2 L3 Preventative Actions R50.00 R00 Legal costs and Legal advice Benefits / Cover Wills, trusts and ante nuptial contracts per benefit cycle iscellaneous matters per benefit cycle R Contractual actions per benefit cycle Contractual actions extensions Actions against Insurers due to repudiation of a motor claim or refused indemnity under such motor 50% 00% policy, subject to the limits applicable to the policy benefit it attaches to and the aggregate limit on the policy per Benefit Cycle, expressed as a percentage of the cost award, limited to the expressed percentage of the contractual actions benefit. Delictual actions per benefit cycle atrimonial actions per benefit cycle (limited to claim per cycle) Criminal proceedings per benefit cycle Labour atters per benefit cycle Limitations of Policy Benefits for any one Benefit Cycle General Extensions Adverse legal costs awards made against you, subject to the limits applicable to the policy benefits it attaches to and the aggregate limit on the policy per Benefit Cycle, expressed as a percentage of the cost award R R R R R R R R % 50% 00% ONTHLY PREIU R25 R45 R00

7 edical Questionnaire. Have you (or your spouse) applied for life assurance in the past five years and not been given cover (i.e. not been accepted),or been given cover at an increased contribution? 2. Have you, your spouse, or any sexual partners ever been tested positive for the AIDS virus, or received treatment or medical advice for AIDS or conditions related to AIDS or the AIDS virus? 3. Have you (or your spouse) during the past year been suffering from unintentional weight loss, persistent night sweats/fever/swollen glands/skin rashes/diarrhoea or persistent digestive disorders? 4. Are you aware of any medical condition that could materially affect you ( or your spouse s ) ability to work over the next to 0 years? 5. Have you ( or your spouse ) been diagnosed with a life threatening decease in the last 2 months? If you answered to any of the above questions, please give details: I,, declare that all the above information is true to the best of my knowledge. Signature Date