international wealth

Suite C 208, La Croisette, Grand Baie, Mauritius | Office: +230 269 4400 Fax: +230 269 6400 | [email protected] | www.international-assurance.com

*All references to International Wealth means International Wealth as a cell constituted under International Assurance Limited PCC

C01V01D24102018 Client Initials……………………… Pg. 2

SECTION 1 : APPLICANT DETAILS

FIRST APPLICANT

Title Date of birth

Surname

First name (s)

Do you wish to be the life assured? Yes No

Physical address

Country and place of birth

Country of residence Nationality

Taxation country of residence Tax reference no

Passport / ID number Expiry date

Tel (home) Tel (mob)

Tel (office) Facsimile

Email address

SECOND APPLICANT

Title Date of birth

Surname

First name (s)


Physical address

Country and place of birth

Country of residence Nationality

Taxation country of residence Tax reference no

Passport / ID number Expiry date

Tel (home) Tel (mob)

Tel (office) Facsimile

Email address

Verification of identity, that is, a certified true copy of the current passport for EACH individual Applicant carrying a photograph of the individual and proof of address must be submitted with this Application Form. Evidence of current address must be no older than 3 months and show physical place of residence. If no proof of address is available for yacht crew, a formal letter from the Captain stipulating his permanent address onboard the yacht, will suffice.

LIFE ASSURED

If you are only insuring the lives of the Applicant/s, and you have ticked the relevant boxes above, please DO NOT complete this subsection. There must be at least one life assured.

Title Date of birth

Surname

First name (s)


Physical address


SECTION 2 : BENEFICIARY DETAILS

FIRST BENEFICIARY

Title

Surname

First name (s)

Date of birth

Country of Residence

Nationality

Passport Number

SECOND BENEFICIARY

Title

Surname

First name (s)

Date of birth


Nationality

Passport Number

THIRD BENEFICIARY

Title

Surname

First name (s)

Date of birth


Nationality

Passport Number

Verification of identity, that is, a certified true copy of the current passport for EACH individual Applicant carrying a photograph of the individual and proof of address must be submitted with this Application Form. Evidence of current address must be no older than 3 months and show physical place of residence. If no proof of address is available for yacht crew, a formal letter from the Captain stipulating his permanent address onboard the yacht, will suffice.

SECTION 3 : INVESTMENT DETAILS

INVESTMENT DETAILS

Pre-allocated policy number

BASIS OF CONTRACT

Plan Reporting Currency USD EUR GBP

*Please select only one

Your valuations will be denominated in the currency selected above.


Total Amount invested Currency……………….………….………. Amount……………….………….……….

Currency……………….………….………. Amount……………….………….……….

Currency……………….………….………. Amount……………….………….……….

SOURCE OF FUNDS

APPLICANT 1 APPLICANT 2

Occupation Details & Income

Estimated income p.a. (applicant)

Estimated income p.a. (spouse)

Occupation

Applicant’s Business Name & Address

Size (staff, turnover, etc.)

Applicant (s) visited? Yes No Yes No

If yes, where? Business Premises Home Business Premises Home

If yes, by who? Frequency?

Gifts & Inheritance

Name of benefactor

Name of beneficiary

Relationship between benefactor beneficiary and applicant

Amount received

Date received

Disposal of a Business or a Significant Asset

Details (business/significant asset)

Name of owner

Relationship between the owner of business/asset and applicant

Amount received

Date received

Net Worth APPLICANT 1 APPLICANT 2

Approximate net worth

Up to USD 1 mil

Up to USD 2 mil

Up to USD 5 mil

Up to USD 10 mil

Up to USD…………………………….

Up to USD 1 mil

Up to USD 2 mil

Up to USD 5 mil

Up to USD 10 mil

Up to USD…………………………….


Other Information

Any public position currently or previously held? (if Yes, please provide details above)

Yes No Yes No

DECLARATION

This information originates from my first-hand knowledge of the client's circumstances (if this is not the case, the reasons are)

...................................................................... ...................................................................... Financial Advisor’s Signature Date ...................................................................... ...................................................................... First Applicant’s Signature Date ...................................................................... ...................................................................... Second Applicant’s Signature Date Please provide supporting evidence where necessary.

INVESTMENT INSTRUCTIONS

Please enter the percentage to be invested per Fund below.

FUND NAME ISIN or SEDOL FUND CURRENCY

% OF INVESTMENT FOR EACH FUND

SCW VOYAGE FUND

SCW CRUISE FUND

SCW ANCHOR FUND

SCW TECH EVOLUTION FUND

CASH ACCOUNT (Please note, 3% of your investment will always be

allocated to cash)

3%

TOTAL PERCENTAGE 100% 100%


SECTION 4 : INVESTMENT MANAGEMENT

MANAGING YOUR INVESTMENTS

APPOINTMENT OF FINANCIAL ADVISOR

I/We appoint the Financial Advisor to act in the capacity of an advisor to my/our policy. 1. I/ We understand that the Financial Advisor will act on my/our behalf in accordance with the terms and conditions specified in sections

below, to advise on and change the investment portfolios to which the value of my/our policy is linked. I authorise International Wealth to provide all relevant information relating to my/our policy to my/our Financial Advisor when requested.

2. I/We agree that International Wealth shall not be responsible for any loss or liability incurred to my/our policy as a result of the actions, or failure to take actions, by my/our appointed Financial Advisor.

3. I/we agree to indemnify International Wealth, the Company, its officers, all shareholders in and the directors of the Company and cells and holds them harmless against any claims that might hereafter be made against them arising from this arrangement.

4. I/ We confirm that all communications in relation to investment instructions should be directed to my/our Financial Advisor. 5. I/We confirm that I/We will inform International Wealth in writing immediately, should I/We decide to change my/our Financial Advisor

or bring this agreement to end in the future. 6. I/We acknowledge that International Wealth has the right to reject the appointment of my/our Financial Advisor at its discretion and

that International Wealth is entitled, at its absolute discretion, to refuse or accept an investment instruction properly given by the Financial Advisor.

AUTHORITY GRANTED

Non-discretionary authority: I/We confirm that the Financial Advisor will be acting on a non-discretionary basis. This means that the Financial Advisor will discuss any proposed alterations to the composition of the Investment Portfolio with me/us and that they must have my/our prior written agreement before any investment instructions are forwarded to International Assurance Limited PCC. I/We authorise International Assurance Limited PCC to act upon the investment instructions of the Financial Advisor as confirmed by myself/us in writing. Investment instructions may be forwarded to International Assurance Limited PCC only with my/our prior consultation., or *

FINANCIAL ADVISOR DETAILS AND CONDITIONS (This section should be completed by the Financial Advisor)

FINANCIAL ADVISOR’S NAME MIA STEENKAMP

FINANCIAL ADVISORY FIRM NAME SOUTHERN CROSS WEALTH LIMITED

ADDRESS

Coastal Building, Wickham’s Cay 2, P.O. Box 2221,

Road Town, Tortola, British Virgin Islands.

EMAIL ADDRESS [email protected]

TELEPHONE NUMBER +27 (0)76 543 2868

DECLARATION BY FINANCIAL ADVISOR In our/my capacity of Financial Advisor to this policy, I/we agree to the following terms and conditions: 1. All instructions should be received in a format as agreed by International Wealth. 2. International Wealth reserves the right to accept/reject any instruction from the Financial Advisor. 3. The Financial Advisor agrees to provide copies of discussions with the Policyholder, for evidence, where the Financial Advisor is acting

on a non-discretionary basis. The Financial Advisor has the duty to maintain these records. 4. The Financial Advisor confirms that it has such authorisations and licences with such regulatory bodies as is necessary to act as

appointed Financial Advisor and agrees to notify International Wealth in writing, immediately should this authorisation change or cease. 5. International Wealth reserves the right to remove the Financial Advisor from the Policy without specifying a reason and on giving one-

month written notice to the Policyholder and the Financial Advisor. 6. The Financial Advisor may resign his appointment by giving one month’s written notice to the Policyholder and International Wealth.


7. The Financial Advisor appointment shall cease immediately upon the death, bankruptcy, dissolution, conviction for criminal offence or insolvency of the Financial Advisor or if the Financial Advisor is in beach of any regulatory requirement or it becomes illegal for the Financial Advisor to act in this capacity.

8. The Financial Advisor confirms that they have independently verified all the relevant applicants’ identities and personal details, as disclosed in this Application Form, and enclose certified copies of all requisite documents for International Wealth’s records.

9. The Financial Advisor confirms that they have known the Applicant(s) for …………….. year(s) and are not aware of any reason why this investment should not be concluded.

10. The Financial Advisor confirms that they have taken reasonable steps to ensure that the Applicant(s) funding is legitimate to the best of their knowledge; all the information provided by the Applicant(s) is true and complete and has been obtained by them, from the Applicant(s).

11. The Financial Advisor declares that, to the best of their knowledge and belief, the information given in this Application Form is true and complete.

12. The Financial Advisor declares that they have not made any changes to the Application form after the authorised signatories/Applicant have signed it.

13. The Financial Advisor declares that they have informed the Applicant(s) of International Wealth’s Data Protection and Privacy Policy and explained to the Applicant(s) their rights as Data Subjects in relation to the Data Protection Act 2017.

...................................................................... ...................................................................... Financial Advisor’s Signature Date ...................................................................... ...................................................................... First Applicant’s Signature Date ...................................................................... ...................................................................... Second Applicant’s Signature Date

SECTION 5 : CHARGES SCHEDULE

ESTABLISHMENT CHARGES

No Initial Establishment fee is charged; however the Financial Advisor may negotiate an initial establishment fee with the investor. Please note that if no fees have been specified, 0% will apply.

INTERNATIONAL WEALTH ESTABLISHMENT CHARGE 0.25% only if the Financial Advisor's fee is > than 0%

Please tick if applicable.

Advisor Initial Fee (maximum charge 3%) .........%

ONGOING FEES

INTERNATIONAL WEALTH

QUARTERLY POLICY FEE USD 50

ADMINISTRATION FEE 0.35% p.a.


ONGOING ADVISORY FEE

Please note, if the investor exits the policy within 24 months, an exit penalty will be charged whereby the remainder of the ongoing Advisory fee that the investor would’ve paid, will be deducted from the final amount withdrawn.

1.25% p.a.

...................................................................... ...................................................................... Financial Advisor’s Signature Date

...................................................................... ...................................................................... First Applicant’s Signature Date

...................................................................... ...................................................................... Second Applicant’s Signature Date

SECTION 6 : APPLICANT/S DECLARATION

1. I/We, the applicant (s), warrant in favour of International Wealth that:1.1 I/We confirm that we have read the product literature including the policy Terms and Conditions.1.2 I/We hereby consent to receiving our Policy Schedule and Terms and Conditions in digital format (should the

Applicant(s) wish to receive their Policy Schedule and Terms and Conditions in paper-based form, then the Applicant(s) should notify International Wealth of their requirement).

1.3 By signing this Application, I/we agree to the policy being governed by the policy Terms & Conditions. I/We confirm that all of the information we have provided in this application, along with any supporting forms, questionnaires, statements, reports or other information are true and complete.

1.4 I/We confirm that to the best of our knowledge and belief, I/we am/are not subject to any legislation that would make our investment into this policy unlawful.

1.5 I/We am/are aware that International Wealth does not provide investment advice, is not responsible for managing the investments and does not determine whether or not investments are suitable for me/us. I/We understand that International Wealth offers access to a range of investment instruments including funds, shares, ETF’s and structured notes offered by external companies. I/We accept that ultimate responsibility for the selection of investments lies with me/us and/or our appointed Financial Advisor; if funds underperform and as a consequence the policy drops in value, I/we accept this is not the fault of International Wealth.

1.6 I/we request that International Wealth allocates my/our premium to the investments selected as part of this Application. In order for International Wealth to do this I/we confirm the following:

a) I/We agree to International Wealth acting on instructions received from me/us or my/our appointed FinancialAdvisor, and I/we will read the documentation issued by the fund manager/product promoter for eachinvestment prior to selecting it for my/our policy.

b) I/We are aware that some investments may have terms and conditions that could:

• restrict International Wealth from realising a cash value when requested and prevent InternationalAssurance paying out benefits from the policy in a timely fashion.

• result in International Wealth having to pay back some or all of the sale proceeds if an adjustment has to bemade after the payment. If International Wealth is required to make such a repayment and the policy valueis too low to cover it, or I/we have surrendered the policy, I/we agree to compensate International Wealthfor any loss that it has suffered as a result.

c) I/We accept that International Wealth has the right to sell funds linked to the policy without requiring my/our permission.

International Wealth may do this if it decides that a fund may have harmful legal, tax or other consequences under law.

d) I/We are aware that there may be fees to pay when International Wealth sells one or more of the investments linked to the

policy. Any fees due when selling an investment should be detailed by the fund manager/product promoter in the fund/product

documentation.

e) I/We confirm that I/we are aware of the fees that I/we may pay in relation to my/our chosen investments.

1.7 I/We have fully familiarised ourselves with any applicable income tax and exchange control laws and regulations regarding the purchase of investments.


1.8 I/We are not prevented or restrained legally, commercially or otherwise from purchasing the product from International Wealth in accordance with the terms of this application.

2. I/We hereby indemnify International Wealth, the Company, its officers, all shareholders in and the directors of the Company and cells and hold them harmless against any claims that might hereafter be made against them arising from the purchase or sale of any investments.

3. I/We declare that I/we am/are not, nor are any beneficiaries nor lives assured, resident in Mauritius for the purpose of the Income Tax Laws in force in Mauritius and undertake to notify International Wealth if this declaration ceases to be correct.

4. I/We understand that our application will not be accepted unless cleared funds and the applicable Know Your Client information has been received with valid supporting documentation. Details of the required additional documentation are available on request from your Financial Advisor. The Compliance Officer reserves the right to request any further documentation as and when required.

5. I/We the undersigned, confirm that we have read this application and accept the terms and conditions, which may be amended from time to time. The Terms & Conditions are also available on the company’s website – www.international-assurance.com

6. We acknowledge and agree that: 6.1 International Wealth has informed us that it has a Data Protection and Privacy Policy which is available on its website as

a download; 6.2 International Wealth has informed us that it has a Complaints Handling Policy which is available on its website as a

download; 6.3 information provided to International Wealth by us will be stored on their computer systems and manually by its agents

and delegates; 6.4 I/We as the Guardian/ Parent of the Child (minors under the age of 16 years of age) under the beneficiaries section of

this application form hereby consent to the use of the Data provided; 6.5 for the purposes of the Data Protection Act 2017 in force in Mauritius (the “Data Protection Law”) and other relevant data

protection legislation which may be applicable, International Wealth is required to specify the purposes for which it will hold personal data. International Wealth will only use such information for the purposes set out below (collectively, the “Purposes”), being to: 6.5.1 process our personal data (including sensitive personal data) as required by or in connection with our investments with

International Wealth including the processing of personal data in connection with credit and money laundering checks on ourselves;

6.5.2 communicate with us as necessary in connection with our affairs and generally in connection with our investments with International Wealth;

6.5.3 provide personal data to such third parties as International Wealth may consider necessary in connection with our affairs and generally in connection with our investments with International Wealth including to third parties outside Mauritius;

6.5.4 without limitation, provide such personal data to the Financial Advisor, notwithstanding that any such party may be outside Mauritius;

6.5.5 transfer personal data to other companies within the same group as International Wealth (including to any such companies which are outside Mauritius), including by means of electronic communications;

7. I/We declare that the information provided in this application and any additional documentation is true and complete to the best of our knowledge and that we agree to provide additional information if requested by International Wealth. 7.1 I/We understand our rights as Data Subjects as detailed in International Wealth’s Data Protection and Privacy Policy and that I/we

have the rights to: 7.1.1 on written instruction, request International Wealth to provide us/me, without excessive delay and free of charge,

confirmation as to whether or not personal data relating to ourselves is being processed and a copy of the data processed. 7.1.2 on written instruction, request International Wealth to provide me/us with details of how it protects our personal data. 7.1.3 on written instruction, request International Wealth to restrict the use of our personal data. 7.1.4 on written instruction, request International Wealth to amend any personal data it holds on ourselves. 7.1.5 on written instruction, request International Wealth to destroy the Data held on ourselves (unless the keeping of said Data is

required by Law). 8. I/We declare that the information provided in this application and any additional documentation is true and complete to the best of

our knowledge and that we agree to provide additional information if requested by International Wealth. 9. In providing International Wealth with information, i/we hereby represent and warrant to International Wealth that i/we have obtained

the consent of any data subjects other than ourselves to the International Wealth holding and using their personal data for the purposes other than the purpose set out above (including the explicit consent of the data subjects for the processing of any sensitive personal data for the purposes set out above) and that we will use our best endeavours to obtain the consent of the data subjects to International Wealth and using personal data for the processing of any personal data for the purpose set out above. For the purposes of this application form, “data subject”, “personal data” and “sensitive personal data” shall have the meanings attributed to them in the Data Protection Law.

10. I/We understand that International Wealth does not provide legal/tax or financial advice and it is our responsibility to seek independent legal/tax or financial advice before completing the application form.

11. I/We declare that all monies transferred to International Wealth or its agents/delegates come from legitimate sources and agree to further justify the source of the funds to International Wealth on request.

12. I/We understand that we are solely responsible for investments in International Wealth, the value of which may rise or fall and that there is no financial guarantee against loss of investment.

13. I/We hereby authorise International Wealth to accept facsimile/e-mail/other electronic documents and instructions regarding our International Wealth Portfolio Bond (hereafter referred to as ‘electronic documents and instructions’). I/We accept that if we suffer any loss as a result of International Wealth’s acceptance or interpretation of any electronic documents and instructions coming from or purporting to come from us or our Financial Advisor, I/we shall have no claim against International Wealth. I/We further agree to indemnify International Wealth against any claims, demands, proceedings or actions which may be brought against International Wealth (by any person, including us) and against any liabilities, costs, charges, losses or expenses incurred directly or


indirectly by International Wealth as a result of it acting in accordance with any electronic documents and instructions given (other than where there is fraud, gross negligence or wilful misconduct on the part of International Wealth or its officers or employees).

14. I/We agree to this policy being governed by Mauritius law and to the Courts in Mauritius having the right to decide any case that may be brought in relation to this policy.

...................................................................... ...................................................................... First Applicant’s Signature Date ...................................................................... ...................................................................... Second Applicant’s Signature Date

SECTION 7 : RISK DISCLOSURE

In connection with the purchase of the financial instruments listed above, I/we the undersigned policyholder/applicant/s declare that: 1. I/We understand that we are solely responsible for reviewing any investment into any fund, share, ETF, interest in a certificate, note or

debenture or other security or financial instrument, its offering and any statements made by an investment manager, sponsor or promoter and for performing such due diligence as we may deem appropriate, including consulting our own legal and tax advisers, and that any information provided by International Assurance Limited PCC (“IAL”) shall not form the basis of our investment decision.

2. I/We understand that any investment promotional material, including brochures, leaflets or fact sheets, presented to us have been provided by our Financial Advisor and are not from IAL. IAL does not represent that such material is accurate, complete, and/or up-to-date and, if applicable, time indicated nor does IAL not accept any responsibility to update any opinion, analyses or other information contained in the material. The material presented to us has been provided by our Financial Advisor is for my/our information only and is not an offer or solicitation to buy or sell any investment into any fund, share, ETF, interest in a certificate, note or debenture note or other security or financial instrument.

3. I/We understand that some investments may not be appropriate for me/us. These investments can be speculative and may involve a high degree of risk, above and beyond those associated with traditional asset class investments and we could lose all or a substantial amount of our investment. Many investments have eligibility requirements for participation, generally only available to high net worth individuals and professional investors.

4. I/We understand that some investments are not regulated, are not collective investment schemes and are not subject to the same regulatory requirements as collective investment schemes. Some investments may use leverage and other speculative investment practices that may increase the risk of capital loss. These investments may have performance that is volatile and may hold investments that are illiquid.

5. I/We acknowledge that I/we have been made aware by our Financial Advisor of the risks associated with the financial instruments listed above and accept all of the aforesaid risks which may result in financial loss and hereby waive and abandon any right to hold IAL responsible therefore.

6. I/We agree that IAL is hereby indemnified against any loss or damage suffered by us in connection with the said purchase/s as described above.

7. I/We acknowledge that the financial instruments listed above may have a charging structure that might include various fees and

commissions and that these have been disclosed by our Financial Advisor to us.

8. I/We agree that I/we will remain liable for any and all of the International Wealth's administrative and policy fees during any period in

which the purchase, sale, transfer, trade of and/or investment in any investment instrument that is suspended or impaired in any

manner whatsoever.



SECTION 8 : SIGNATURES

SIGNATURES

I/We the undersigned hereby confirm our acceptance of and having read and understood this application. I/We the undersigned agree to the following documents forming the basis of the contract between me/us and International Wealth: • this Application Form • the Terms and Conditions • the Policy Schedule • any Endorsements to the Policy Schedule ...................................................................... ...................................................................... Financial Advisor Signature Date Signed ...................................................................... ...................................................................... First Applicant Signature Date Signed

...................................................................... ...................................................................... Second Applicant Signature Date Signed


SECTION 9 : PAYMENT DETAILS

PAYMENT METHOD

Share Transfer Telegraphic Transfer

INVESTOR BANK DETAILS

NAME OF BANK

ADDRESS OF BANK

COUNTRY

ACCOUNT NAME

ACCOUNT NUMBER

SWIFT / BIC

IBAN CODE

Transfers to the applicant will only be transferred to the above-mentioned account.

TELEGRAPHIC TRANSFER: PAYMENT

PLEASE PAY TO

NAME OF BANK THE MAURITIUS COMMERCIAL BANK

ADDRESS OF BANK SIR WILLIAM NEWTON STREET, PORT LOUIS, MAURITIUS

COUNTRY MAURITIUS

ACCOUNT NAME INTERNATIONAL ASSURANCE LIMITED PCC

SWIFT/BIC MCBLMUMU

REFERENCE (Name or Policy No)

Please tick the appropriate currency and account:

CURRENCY ACCOUNT NO. IBAN

GBP

EUR

USD

000011857161

000011857188

000011857013

MU05MCBL0901000001857161000GBP

MU11MCBL0901000001857188000EUR

MU76MCBL0901000001857013000USD


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