OPN ENDOWMENT PLAN APPLICATION FORM

OPN ENDOWMENT PLAN APPLICATION FORM PROFESSIONAL PROVIDENT SOCIETY INVESTMENTS PROPRIETARY LIMITED ( PPS INVESTMENTS ) CLIENT SERVICE CENTRE CONTACT DETAILS TEL: 0860 468 777 (0860 INV PPS) FAX: 021 680 3680 EMAIL: admin@ppsinvestments.co.za WEBSITE: www.ppsinvestments.co.za Please complete the form in BLOCK LETTERS Please indicate all options selected with an [X] Please initial any amendments made Please note, Investment Option(s) refer to the underlying unit trusts within your portfolio FICA requirements are available on the PPS Investments website Please note, the Administrator refers to Old Mutual Investment Administrators Proprietary Limited, which is a licensed Financial Service Provider Please note, FATCA refers to the Foreign Accounts Tax Compliance Act General Terms, Conditions and Declarations are available on the PPS Investments website A CONTACT PERSON FOR OUTSTANDING REQUIREMENTS Name and surname Telephone number Capacity Email B PERSONALISED POLICY NAME You have the opportunity to choose your own policy name (e.g. My Holiday Fund ). Name my investment Please note that the product does not guarantee performance in line with your personalised policy name. C PERSONAL DETAILS OF POLICYHOLDER New policyholder Existing policyholder Client number (if existing policyholder) Type of policyholder Natural person Company Other institutions (e.g club / church / school) Partnership Close Corporation Trust Title or Name of entity or initials, surname and designation of contact person of entity Date of birth Country of birth / Country of registration Identity or passport number / Registration number of entity Country of passport issued / Country of entity registration Nationality Gender Male Female Home language English Afrikaans Other (please specify) Country of residence South African Other (please specify) Are you resident for tax purposes in the Republic of South Africa? Yes No If you answered yes, provide the RSA income tax reference number. Income tax reference number / / / Are you resident for tax purposes in any other country than the Republic of South Africa? Yes No If you answered yes, please list the country or countries in which you are resident for tax purposes, together with any tax reference number(s) / tax identification numbers, if relevant. Country Tax reference number / / / Physical address Postal code PAGE 1 OF 8 A policy issued by Coronation Life Assurance Company Limited under the Long-term Insurance Act, No. 52 of 1998 - OPN forms part of the comprehensive PPS Investments suite of products. October 2014

Postal address Postal code Telephone number (home) Telephone number (work) Cellphone number Email Preferred communication method Email Post Send me the PPS Investments daily market indicators via SMS Yes No Source of funds for this investment Earnings / Liquidation of Property Gift / Donation salary investment disposal inheritance Other (specify) Personal details of the life assured Title Date of birth Identity or passport number D ACTING ON BEHALF OF THE POLICYHOLDER E.g. Guardians / Persons with Power of Attorney or mandate acting on behalf of the policyholder. Proof to be sent to PPS Investments. Title Identity or passport number Relationship to the policy holder Postal address Postal code Telephone number Cellphone number Email E LUMP SUM INVESTMENT DETAILS Lump sum contribution (minimum R10 000) Phasing-in details Lump sum amounts can be made directly into the Investment Option(s) of your choice or can be phased in over a period of time. If this option is selected, all monies should be invested in the PPS Enhanced Yield Fund and will be phased into your selected Investment Option(s). Investment to be phased in Yes No If Yes, please select phase-in period 3 months 6 months 12 months Phase-ins will be generated on the 9 th of the month, and priced on the 10 th. Should either of these days fall on a weekend or public holiday, the process will take place on the following business day. F DEBIT ORDER INVESTMENT DETAILS Please note that your first debit order payment must be deducted from your bank account and may not be paid in cash. Debit order amount (minimum R500) Commencement month Collection date 1 st 7 th 15 th 28 th (not within 14 days of commencement date) Frequency Monthly Quarterly Half-yearly Yearly Annual escalation rate 5% 10% 15% % PAGE 2 OF 8

It is recommended that you escalate your debit order amount annually in order to ensure your contributions are in line with inflation. G Should the cut-off for my selected debit order date be missed, please commence on the same day of the following month; or as soon as possible, on the next collection date. BANK DETAILS Bank details of policyholder The following bank details will be used for all payments. A cancelled cheque or recent bank statement (not older than three (3) months and clearly displaying your name and the bank's logo) must accompany this application form as confirmation of these details. Any changes to your banking details in future must be forwarded in writing to PPS Investments together with proof thereof. Title Initials / Name of entity Identity or passport number / Registration number of entity Bank Account number Branch Branch code Type of account Cheque Savings Transmission I, the undersigned, request and authorise PPS Investments to arrange to collect / deposit any monies payable from / to the bank account specified above. Use the bank details below for the recovery of my debit order and / or lump sum investment, as the payer differs from the policyholder (please provide proof of bank details such as a cancelled cheque or a bank statement not older than three (3) months, a copy of the ID of the payer and a specimen signature of the payer). Collection requests from a third party legal entity s account must be accompanied by a resolution, copies of the ID documents and signatures of the signatories of the third party as well as all supporting documents. Bank details of third party Title Initials / Name of entity Identity or passport number / Registration number of entity Bank Account number Branch Branch code Type of account Cheque Savings Transmission I, the undersigned, request and authorise PPS Investments to arrange to collect the monies payable from the bank account specified above. Signature of account holder / Signatory Date H METHOD OF PAYMENT Cheque deposit* All cheques must be endorsed as Non Transferable and deposited directly into the product s bank account. Electronic / Internet transfers* Electronic transfers may not reflect immediately and may take a few days to appear in the product s bank account. Regular debit order Please ensure that the bank account details are completed in the relevant section if you select this option. The reference on your bank account will be a combination of the abbreviated product name (OPN END1) and a 16-digit policy number e.g. OPN END1 POL1234567890123. Electronic collection by the Administrator Electronic collection is restricted to a maximum of R500,000 per debit. An amount greater than this will require the Administrator to make multiple debits, which may result in additional transaction costs. The investment process will take one (1) business day longer per debit. The reference on your bank account will be a combination of the abbreviated product name (OPN END1) and a 12-digit client number e.g. OPN END1 123456789012. Please ensure that the amount is available for collection upon submission of your instruction. If an investment contribution is collected electronically from your bank account, the amount that you have contributed cannot be withdrawn from your OPN Endowment Plan within the next 30 days. PAGE 3 OF 8

Please do the electronic collection on (date) * The Administrator requires proof of deposit or transfer, together with receipt of the applicable documentation as set out in this form, before the application can be processed. Please reference your deposit using your contact number, followed by your name and surname. For example, 0825554444 John Smith. I INVESTMENT OPTION(S) I hereby apply to invest in the Investment Option(s) indicated below, which are made available by PPS Investments. For a comprehensive list of available Investment Option(s), please refer to the Investment Option Schedule available on www.ppsinvestments.co.za or from the PPS Investments Client Service Centre and indicate your selection in the table below. The available Investment Option(s) may change from time to time. Please ensure that the percentages are completed for the lump sum and debit order investment column, where applicable 1. 2. 3. 4. 5. 6. 7. 8. 9. Investment Option Lump sum investment % Debit order investment % 10. Total 100% 100% J You are required to nominate at least one beneficiary who may receive a benefit following the death of the life assured under this policy. If you elect to review and make changes to the nomination of any beneficiaries, a signed instruction must be received before the death of the life assured. Relationship Gender ID / Passport number Percentage BENEFICIARY NOMINATIONS FOR PROCEEDS Beneficiary 1 Beneficiary 2 Postal address Contact number Beneficiary 3 Beneficiary 4 Relationship Gender ID / Passport number Percentage Postal address Contact number If there are additional beneficiaries, please attach this information on a separate signed page. Please ensure the total percentages nominated are equal to 100%. PAGE 4 OF 8

K BENEFICIARY NOMINATIONS FOR OWNERSHIP You are required to nominate a beneficiary who may receive a benefit following the death of the life assured under this policy. If you elect to review and make changes to the nomination of your beneficiary, a signed instruction must be received before the death of the life assured. Relationship Gender ID / Passport number Postal address Beneficiary 1 Contact number L COMPULSORY COMPLETION BY POLICYHOLDER Are you married? Yes No If yes, are you married in community of property? Yes No If yes, have you nominated a beneficiary other than your spouse? Yes No If yes to all the above, you require your spouse s written consent. Name of spouse Signature of spouse M TERMS, CONDITIONS AND DECLARATIONS I understand and agree to be bound by the provisions of this application form. If on the date of signature of this application form an updated application form exists and fees and General Terms, Conditions and Declarations differ, the updated application form, fees and General Terms, Conditions and Declarations will apply. I understand and agree that: In the event that PPS Investments is unsuccessful in its efforts to pay any benefits due to me or my beneficiaries for whatever reason, such benefits will become unclaimed benefits and will be dealt with in accordance with the standard on unclaimed assets by the Association of Savings and Investment South Africa ( ASISA ). See the PPS Investments website for the detailed process (www.ppsinvestments.co.za). It is my responsibility to ensure that my personal and contact particulars are correct. If this is not the case, or in the event that my personal and / or contact particulars change, it is my responsibility to inform PPS Investments in writing of the incorrect particulars or the change in particulars. PPS Investments may use all personal and contact information provided to PPS Investments by me in order to facilitate my tracing in respect of any unclaimed benefits. I also agree that PPS Investments may share all personal and contact information with any third party, or obtain any contact and personal information from any third party, in order to facilitate my tracing in respect of any unclaimed benefits. The information contained herein is correct. If this application form is signed in a representative capacity, I have the necessary authority to do so and this transaction is within my powers. I will have fourteen (14) days after receipt of the policy confirmation to report any errors to PPS Investments. I am acting for my own account. I have considered the suitability of this product and made my decision to enter into this policy without relying on any communication from PPS Investments, whether written, oral or implied, as advice or a recommendation to enter into the policy. I understand that information and explanations relating to the terms of this policy is not to be considered advice or a recommendation to enter into any transaction. PPS Investments will not be responsible for any failure, malfunction or delay of any networks, electronic or mechanical device or any other form of communication used in the submission, acceptance and processing of applications and / or transactions. PPS Investments will not be liable to make good or compensate any policyholder or third party for any related damages, losses, claims or expenses. I am aware of the PPS Investments Investment Option Schedule (available on www.ppsinvestments.co.za), which details the Investment Option(s) available on the PPS Investments platform and sets out the fees which may be applicable to my policy (including administration fees, asset management fees and any rebates allocated by the management companies of the respective Investment Option(s)). The General Terms, Conditions and Declarations (available on www.ppsinvestments.co.za or on request from the PPS Investments Client Service Centre on 0860 468 777 or at clientservices@ppsinvestments.co.za) have been clearly understood by me. Application The OPN Endowment Plan is a PPS Investments product issued under the life licence of Coronation Life Assurance Company Proprietary Limited ("Coronation Life ) under the provisions of the Long-Term Insurance Act, No.52 of 1998 in the name of the policyholder. An approved Administrator appointed by Coronation Life from time to time administers the OPN Endowment Plan. The current Administrator is Old Mutual Investment Administrators Proprietary Limited ("the Administrator"), which is a licensed Financial Services Provider. I hereby apply for an OPN Endowment Plan and agree to be bound by the Terms, Conditions and Declarations contained in this application form as well as PPS Investments' General Terms, Conditions and Declarations (as amended from time to time). This application does not create any obligation for PPS Investments until it has been accepted in writing by PPS Investments. Date PAGE 5 OF 8

I hereby apply for an OPN Endowment Plan and agree to be bound by the Terms, Conditions and Declarations contained in this application form as well as PPS Investments' General Terms, Conditions and Declarations (as amended from time to time). This application does not create any obligation for PPS Investments until it has been accepted in writing by PPS Investments. I understand and agree that this application, together with my policy confirmation and PPS Investments' General Terms, Conditions and Declarations as well as any other related documents provided by me and accepted by Coronation Life, will govern the legal relationship between myself and Coronation Life. I am aware that the OPN Endowment Plan is subject to a thirty (30) day cooling-off period. This gives me the right to withdraw from the OPN Endowment Plan by giving PPS Investments written notice within thirty (30) days of receipt of my policy confirmation and terms and conditions. A disinvestment will be made at the earliest opportunity after the date the written request is accepted by PPS Investments, at the price then applicable. The amount to be refunded will consider market fluctuations and may therefore be less than the initial contribution amount. No interest or investment return will be paid or accrue to me. This option is not available where, during the thirty (30) day period, I have switched from the portfolios originally invested in, or if any benefit or claim has been paid. Product Terms, Conditions and Declarations I confirm that I have noted the following: The value of my policy will increase or decrease as the market values of the underlying securities in my chosen Investment Option(s) fluctuate. I understand that I carry this investment risk. PPS Investments does not provide any guarantees in relation to any investment performance. Investment Option(s) are generally medium to long-term investments. The value of the units in these Investment Option(s) may increase or decrease and past performance is not necessarily a guide to future performance. I am aware of the impact that a downturn in the market will have on my capital. The initial term of the OPN Endowment Plan is five (5) years, as this is the minimum term allowed by the Long-term Insurance Act, No. 52 of 1998. This Act also restricts liquidity during this period to a maximum of one (1) restricted withdrawal during the period. At the end of the initial five (5) year term, the term of the OPN Endowment Plan automatically becomes open ended. A withdrawal will only be permitted in respect of a OPN Endowment Plan that has been ceded as security if the prior written consent of the cessionary has been received by PPS Investments. Ownership of the OPN Endowment Plan may be transferred to another person by outright cession and the OPN Endowment Plan may be ceded as security. I understand that I may not transfer my OPN Endowment Plan to another endowment policy or transfer another endowment policy into the OPN Endowment Plan and I may not borrow from my OPN Endowment Plan. Statutory charges such as Dividend Withholding Tax, Income Tax and Capital Gains Tax will be recovered from the OPN Endowment Plan. N INTERMEDIARY FEES I acknowledge that I did not receive any financial advice. I will be noted as a PPS Investments No Financial Intermediary policyholder. I acknowledge that I have received financial advice from the financial intermediary whose details are completed in the section below. This is my appointed financial intermediary and I agree to the payment of advice fees as follows: Initial lump sum fee Initial debit order fee Ongoing fees per annum Fees must be paid from A specific Investment Option Max. 3.42% (incl. VAT) Max. 3.42% (incl. VAT) Max. 1.14% (incl. VAT) Please note that this selection will apply to all of your investments and / or policies. If you have an investment / policy for which this Investment Option has not been chosen, fees will be paid from all Investment Option(s) proportionally. All Investment Option(s) proportionally The Administrator will pay ongoing fees to your financial intermediary on your behalf and will recover these fees from your policy. These fees will therefore accrue to the Administrator as an additional fee over and above the administration fee applicable to our policy in terms of the PPS Investments fee structure. Is this proposal to replace the whole or any part of your existing policy with any Product Provider / Supplier (whether replacement is to occur immediately or to replace a policy discontinued within the past four months or within the next four months)? Please indicate your submission Yes No If "Yes", the financial intermediary must discuss and complete the Replacement Policy Advice Record and attach it to this application form. Does this proposal constitute a replacement of an investment with a recurring premium that will lead to or has led to the levying / deduction of a termination charge (causal event charges and administration charges) of more than 15% of the replaced investment value? Refer to the definitions in Part 3 of the Regulations to the Long-Term Insurance Act, 1998 (commission regulations). Please indicate your submission Yes No I hereby confirm that I,, have read and understand the terms and conditions as set out in the General Terms, Conditions and Declarations. I also certify that the information provided in terms of the FATCA is correct and that unless stated otherwise, I am not a tax resident of the United States of America. Signature of policyholder Date PAGE 6 OF 8

O INTERMEDIARY DETAIL AND DECLARATION Intermediary name Intermediary institution Intermediary code Contact number FSP licence number VAT status Registered Not registered VAT number An accountable institution includes, but is not limited to, the following list of institutions: a bank, long-term insurer, management company registered in terms of the Collective Investment Schemes Control Act, a person who carries on the business of rendering investment advice or investment brokering services (including a public accountant who carries on such a business), member of a stock exchange licensed under the Securities Services Act No.36 of 2004 and a person who has been approved or who falls within a category of persons approved in terms of the Financial Advisory and Intermediary Services Act No. 37 of 2002. If this section is completed by an accountable institution acting on behalf of the client, the supporting documentation as described in "FICA requirements" on www.ppsinvestments.co.za needs not be submitted to the Administrator (but this may be requested where it is deemed necessary). A copy of ID and proof of bank account details are still required. I declare that I am a licensed Financial Service Provider and have made the disclosures required in terms of the Collective Investment Schemes Control Act, No. 45 of 2002, the Financial Advisory and Intermediary Services Act, No. 37 of 2002 and subordinate legislation to the policyholder. I acknowledge and confirm that in my capacity as the primary accountable institution, with PPS Investments being the secondary accountable institution, I have established and verified the identity of the policyholder in accordance with section 21 of the Financial Intelligence Act, 2001 ( the Act ) and I will keep records of such identification and verification according to the provisions of section 22 of the Act. I declare that I have requested and recorded the policyholder s response with regards to replacement and that the client is aware of the possible detrimental consequences of the replacement of the policy. I further declare that 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 policyholder is legally entitled to comprehensive information regarding the consequences of replacement. I warrant that I have explained all fees that relate to this policy to the policyholder and I understand and accept that the policyholder may withdraw his / her authority for payment to me in writing to PPS Investments. Signature of intermediary Date PAGE 7 OF 8

P DETAILS OF THE OPN ENDOWMENT PLAN AND SUPPORTING DOCUMENTATION OPN Endowment Plan bank account details Account name Coronation Life Assurance Company Ltd - OPN Endowment Plan Individuals Bank FNB Branch RMB Corporate Banking - Cape Town Branch code 20-41-09 Account number 622 227 225 23 Account name Coronation Life Assurance Company Ltd - OPN Endowment Plan Companies and Trusts Account Bank FNB Branch RMB Corporate Banking - Cape Town Branch code 20-41-09 Account number 622 227 229 87 Reference Contact number first, followed by your name and surname For example: 082 555 4444 John Smith Supporting documentation Copy of a bar-coded ID bearing ID number and photograph Proof of residential address (e.g. bank statement, utility bill or telephone account not older than six (6) months) Proof of bank details (e.g. bank statement or cancelled cheque not older than three (3) months) For supporting documentation on other entities, please refer to the FICA requirements on our website. Compliance department PPS Investments Tel: 0860 468 777 (0860 INV PPS) 1 st Floor, Travers House Fax: 021 680 3680 Boundary Terraces Website: www.ppsinvestments.co.za 1 Mariendahl Lane Email: compliance@ppsinvestments.co.za Newlands 7700 Please do not hesitate to contact us if you are not satisfied with this investment or the services from PPS Investments. A complaint must be submitted to the Compliance Officer. The contact address of the Compliance Officer is the same as the address above. PPS Investments will acknowledge the complaint in writing and will inform you of the contact details of the person addressing your complaint. The Ombud for Financial Services Providers If you are not satisfied with the response from PPS Investments or if you have a complaint about the advice given by your financial intermediary, you have the right to address your complaint in writing to the Ombud for Financial Services Providers. The Ombud for Financial Services Providers PO Box 7451 Lynwood Ridge 0040 Email: info@faisombud.co.za The Ombud is legally empowered to investigate and adjudicate complaints in a procedurally fair, economical and expeditious manner. PPS Investments (39270) and Professional Provident Society Multi-Managers Proprietary Limited (28733) are licensed financial services providers. Coronation Life Assurance Company Limited is registered in terms of the Long Term Insurance Act 53 of 1998 to carry on long term insurance business. 1 st Floor, Travers House, Boundary Terraces, 1 Mariendahl Lane, Newlands, 7700 Website: www.ppsinvestments.co.za Email: admin@ppsinvestments.co.za PAGE 8 OF 8