Growth Investment Series,

Builder Investment Series,

Business Investment Series
and Income Series

BLUEPRINT PRO FORMA DATA CAPTURE FORM

Registration number 1957/002788/06

Liberty Life – an Authorised Financial Services Provider

EXCEL 2000 02/2011

(Provision of your e-mail address will result in all future correspondence being addressed to you electronically) WTD ID

Policyholder details (Only to be completed if different to the Life Assured)

Title First names

Surname/Fund/Company/Trust Name/CC Gender M F
Company reg./ID number Marital status
Passport Number Country of issue
E-mail address Date of birth
Contact telephone numbers: Home Work
Cell Fax no.
Are you currently insolvent? Yes No If “Yes”, please complete the Insolvency Trustee Statement
Are you a resident of RSA? Yes No
Tax Status of Policyholder: Tax-exempt Body Company/Close Corporation Tax Paying Trust
Non-tax Paying Trust Tax Paying Body Natural Person
Income Tax Reference No. Tax office
Income Category R0 R1 – R4 999 R5 000 – R7 999 R8 000 – R13 999 R14 000 - R29 999 R30 000+
Source of Income Source of Funds for this Investment

Addresses of policyholder/s

To be completed by the Financial Adviser: Do you confirm that these are the Policyholder’s addresses? Yes No
Correspondence address Postal code
Residential address Postal code
Business address Postal code
Please select if the Policyholder would prefer the Summary Policy Document/Documentation to be received via e-mail? Yes No
If “Yes”, please confirm policyholder’s e-mail address.

Life assured (Not for Investment Linked Repayment Option)

Title Full first names

Surname Date of birth / /
Maiden name Gender M F
Marital status Single Married Divorced Widowed Separated Are you a resident of RSA? Yes No
ID number E -mail address
Contact tel. no’s: Home Work Cell Fax no.

Joint life assured

JOINT LIFE (Only applicable for Investment Plan and Investment Builder)
PAYER’S LIFE (Only applicable for Builder Investment Series if the Disability Premium Waiver or Retrenchment Premium Waiver has been selected
on the Investment Builder/Education Builder)
SECOND ANNUITANT (Only Applicable for Joint Life Annuity/Life Annuity with Inflation Protection)

Joint life 1/Payer life/Spouse/Second Annuitant

Title Full first names

Surname Date of birth / /
Maiden name Gender M F
Marital status Single Married Divorced Widowed Separated Are you a resident of RSA? Yes No
ID Number E -mail address
Contact tel. no’s: Home Work Cell Fax no.
Your relationship to the first life assured other than spouse

Please note that in the event of any modification or variation of this standard form Liberty Life will regard this form as being
invalid and of no force and effect. Do not sign blank or incomplete forms.
Page 1
Joint life 2

Title Full first names

Surname Date of birth / /
Maiden name Gender M F
Marital status Single Married Divorced Widowed Separated Are you a resident of RSA? Yes No
ID Number E -mail address
Contact tel. no’s: Home Work Cell Fax no.
Your relationship to the first life assured other than spouse

Joint life 3

Title Full first names

Surname Date of birth / /
Maiden name Gender M F
Marital status Single Married Divorced Widowed Separated Are you a resident of RSA? Yes No
ID Number E -mail address
Contact tel. no’s: Home Work Cell Fax no.
Your relationship to the first life assured other than spouse

Joint life 4

Title Full first names

Surname Date of birth / /
Maiden name Gender M F
Marital status Single Married Divorced Widowed Separated Are you a resident of RSA? Yes No
ID Number E -mail address
Contact tel. no’s: Home Work Cell Fax no.
Your relationship to the first life assured other than spouse

Policy Details

Policy Language English

Source (If not ordinary) Replacement Option Conversion

Plan Details

Growth Investment Series and Living Annuity

INVESTMENT INVESTMENT RETIREMENT LIVING OFFSHORE GUARANTEED

PLAN PLAN WITH ANNUITY ANNUITY INVESTMENT INVESTMENT
INCOME PLAN PLAN PLAN WITH
INCOME
GUARANTEED
INVESTMENT
PLAN

Date of commencement
Retirement age last N/A N/A N/A N/A N/A
Phasing-in Period
2-12 Months N/A
Phasing-in Funds (tick one)
STD Bank Money
N/A N/A
Market
Ermitage Dollar Money
N/A
Market
Ermitage Euro Money
N/A N/A
Fund
Ermitage Sterling Money
N/A N/A
Fund

Page 2
Growth Investment Series and Living Annuity - continued

INVESTMENT INVESTMENT RETIREMENT LIVING OFFSHORE GUARANTEED

PLAN PLAN WITH ANNUITY ANNUITY INVESTMENT INVESTMENT
INCOME PLAN PLAN PLAN WITH
INCOME
GUARANTEED
INVESTMENT
PLAN

Initial Income Level

%
Selected N/A R N/A N/A R
2.5% – 17.5%
Income Escalation Rate
(0% - 10%) N/A % N/A N/A N/A %
Income Frequency
Monthly N/A N/A N/A
Quarterly N/A N/A N/A N/A N/A
Half-annual N/A N/A N/A N/A N/A
Annual N/A N/A N/A N/A N/A
Income Mode
Arrears (only monthly
N/A N/A N/A
allowed)
Advance N/A N/A N/A N/A N/A
Purchase Price R R R R R R

Investment Portfolios Selected

Policy No. 1 Percentage Policy No. 2 Percentage

1. % 1. %
2. % 2. %
3. % 3. %
4. % 4. %
5. % 5. %
6. % 6. %
7. % 7. %
TOTAL 100% TOTAL 100%

Income Series

GUARANTEED LIFE ANNUITY JOINT LIFE SINGLE LIFE GUARANTEE TERM (0 – 20 yrs)
INCOME ANNUITY
st st nd
Term 5 – 20 yrs Reducing to % (1% - 99%) on 1 Death Death 1 Annuitant Death 2 Annuitant

Purchase Price R Payable Monthly in advance Quarterly in advance Half-annual in advance

Annual in advance Monthly in arrears

Date of commencement / /

Income Escalation Rate (0-10%) % p.a.

LIFE ANNUITY WITH JOINT LIFE SINGLE LIFE GUARANTEE TERM (5 or 10 Years)
INFLATION PROTECTION st st nd
(Payable monthly in arrear) Reducing to % (0% - 100%) on 1 Death Death 1 Annuitant Death 2 Annuitant
Date of commencement / / Purchase Price R

Page 3
Builder/Business Investment Series

INVESTMENT BUILDER/ INVESTMENT LINKED RETIREMENT ANNUITY

EDUCATION BUILDER REPAYMENT OPTION BUILDER
SINGLE SINGLE SINGLE
RECURRING RECURRING RECURRING
Date of commencement
Retirement age last
Term N/A 5 to 15 Years
(min. retirement age = 55)
Automatic Premium Increase
0% - 20 % p.a. (in 1% intervals) % % %
CPI (min. 5% p.a. and max 20%
p.a.)
Education CPI (only for Education
N/A N/A
Builder)
Phasing-in Period
2 to 12 Months
(Single premium only)
Source (Single Premium only) N/A N/A Voluntary Compulsory
Recurring Premium Frequency
Monthly
Quarterly (not applicable for
Education Builder)
Half-annually (not applicable for
Education Builder)
Annually
Premium Amount
Recurring Premium R R R

Single Premium R R R
Benefits (For recurring
premiums only)
Disability Premium Waiver N/A

Retrenchment Premium Waiver N/A

Cession (ILRO only)
Please refer to Standard forms, Cessions directory, for the compulsory ILRO cession form that will be automatically called for at new business. Case
will not issue without receipt of this form.

Investment Portfolios Selected

Policy No. 1 Percentage Policy No. 2 Percentage

1. % 1. %
2. % 2. %
3. % 3. %
4. % 4. %
5. % 5. %
6. % 6. %
7. % 7. %
TOTAL 100% TOTAL 100%

Beneficiary details – All products except Investment Linked Repayment Option

First Name, Subsequent initial(s) and Surname National ID Number Relationship to Life Assured/Member % Split
%
%
%
%

Page 4
Occupation Details (Life to be assured) – Builder Investment Series if Disability or Retirement Premium Waiver Benefit is selected
and the payer is the life assured
Do you travel beyond RSA borders in the course of your duties? Yes No

If Yes”, please list country/ies.

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

If Yes”, please provide details.

Nominated occupation Annual Taxable Income R

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

Nature of duties
Occupation Details (Payer life) – Builder Investment Series for Disability Premium Waiver and Retrenchment Premium Waiver
Benefit and the payer is not the life assured
Do you travel beyond RSA borders in the course of your duties? Yes No

If Yes”, please list country/ies.

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

If Yes”, please provide details.

Nominated occupation Annual Taxable Income R

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

Nature of duties

Risk Related Questions – Builder Investment Series and if the Disability Premium Waiver benefit has been selected

Do you or the life to be assured for the premium waiver benefit (if different from the policyholder or first life assured), suffer or Yes No
ever suffered , ever been treated or currently being treated for any physical or mental impairments, (other than for the following
medical reasons)?

Abdominal pain fully investigated Gallstones Pneumothorax as result of trauma

Abortion due to amniocentesis Gastric flu Previous caesarian section
Abruptio placenta Glasses Previous hiatus hernia – surgically removed
Acne Glomerulonephritis – one attack, fully recovered Previous pregnancy
Annual executive medical Heartburn Previous tonsillectomy
Appendectomy Hepatitis A (viral) Previous vasectomy
Army medicals Hiatus hernia treated with medication Prostatitus – one attack
Bronchitis one attack HIV home test kit – negative Psoriasis
Childbirth Hydatiform mole Routine HIV for blood donation – negative
Childhood asthma Hyperthyroidism Routine HIV for pregnancy – negative
Concussion Indigestion Routine/annual gynecological check - up
Cosmetic surgery Influenza/flu/cold Shingles/herpes (zoster)
Cystitis – one attack Insurance HIV – negative Short sighted
Dental check-up Jaundice Sinusitis
Dental Fillings/cappings/braces Kidney Stones – one attack Spastic colon
Dentist Lipoma Splenectomy
Diverticulitis Long sighted Spontaneous pneumothorax
Down’s syndrome child Menisectomy Sprained ankle/wrist – surgically treated
Duodenal ulcer Mumps Sterilization
Eclampsia Nephritis – one attack To have wart removed/burnt off
Ectopic pregnancy Otitis media Tonsillitis
Employment HIV – negative Placenta praevia Uterine rupture
Endometriosis Pleurisy Vasectomy
Fractured/broken bones -no pin insertion Pneumonia – one attack Verucca (wart)
Wisdom teeth
Have you or the life assured for the premium waiver benefit (if different from the policyholder or first life assured), ever been Yes No
refused cover, offered cover on special term, ever claimed or received compensation for injury, dread disease or disability,
other than from a medical aid?
Have you or the life assured for the premium waiver benefit (if different from the policyholder or first life assured), received or Yes No
do you expect to receive any advice, counseling, treatment or blood tests in connection with AIDS or an AIDS related
disorder (other than negative/non-reactive tests for insurance purposes, employment, home test kits or routine tests for
pregnancy or blood donations?

Page 5
Adviser Remuneration

Recurring premium – Builder/Business Investment Series

Investment Builder/Education Investment Linked

Retirement Annuity Builder
Builder Repayment Option
Commission Term Term (5 – 15 years) 5 Years 5 Years
10 Years 10 Years
15 Years 15 Years
Selected Policy Term 20 Years
The above is to the maximum of the 25 Years
selected policy term
Selected Policy Term
The above is to the maximum of
the selected term or the earlier of
the retirement age or age 75 next
birthday

Commission Type (tick one)

0% Upfront & 100% As and When
10% Upfront & 90% As and When
20% Upfront & 80% As and When
25% Upfront & 75% As and When
30% Upfront & 70% As and When
40% Upfront & 60% As and When
50% Upfront & 50% As and When

Commission Discount
Upfront Commission 0% - 100% %
As – and – When Commission 0% - 100% %

Investment Plan

Income Option
Please refer to page 8 for the Advice Fee Mandate, if applicable. Initial Commission % (0% to 1.5%)

Ongoing Commission 0.25% p.a. 0.5% p.a

Income Series (excluding Living Annuity and Guaranteed Income Annuity)

Commission Discount % (0% to 100%)

Retirement Annuity Plan

Initial Commission % (0% to 2.5% (voluntary) or 1.5% (compulsory))

Living Annuity

Initial Commission % (0% to 1.5%)

Guaranteed Investment Plan

Commission Discount % (0% to 100%)

Retirement Annuity Builder

Initial Commission % (0% to 2.5% (voluntary) or 1.5% (compulsory))

Investment Builder/Investment Linked Repayment Option – Single Premium Portion

Initial Advisory Fee % (0% to 5%)

Page 6
Premium Details – All products excluding Offshore Investment Plan, Guaranteed Investment Plan with Income (no once off debits)
and Compulsory Annuities
Account Holder must be the same as the Payer Life if Disability Premium Waiver Benefit or Retrenchment Premium Waiver Benefit/s have
been selected on the Builder Investment Series.
Account type Cheque/Current account Savings account Transmission
Debit Account Credit Account Once off debit (up to R500,000.00) Debit Order date / /
Name of bank

Branch code: Branch name

Account no.:

Initial of account holder Surname/Company name

rd
Account holder relationship Own Joint 3 Party

Tax Details

Annuity and Income payments are subject to Income Tax Regulations. To enable Liberty Life to calculate the correct rate of tax, please
complete the following:

Income tax number Chosen rate of tax % Number of dependants

Tax directive number Tax directive start date / /

Unless a tax directive is submitted to support at lower rates, Liberty Life will be obliged to deduct tax at PAYE rates.
FOR COMPULSORY PURCHASE ANNUITIES:
Purchase monies must be from an approved Pension, Provident or Retirement Annuity Fund
Please specify name of Fund

FICA

Has the policyholder of this policy submitted a proposal with full compliant FICA documentation to you? Yes No

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

Declaration in respect of Financial Adviser’s Details, Replacement Code, Policyholder Protection Rules (PPR) and FAIS.
By submitting an application the Financial Adviser confirms having explained the meaning of replacement to the applicant, that they are potentially
prejudicial, and that the applicant is legally entitled to comprehensive information regarding the consequences of replacement where a replacement
is considered. The Financial Adviser further declares that he/she has provided the applicant with a complete quotation in respect of the policy
applied for, in writing or in a form which is reducible to writing, and generated by current Liberty Life software. He/she also confirms that the applicant
has been provided with all information that is required in terms of the Policyholder Protection Rules and FAIS.

Personal Reference (Internal)

Initials and Surname Personal Code % Split Liberty Life Code

Signatures

Signed at this day of 20

Signature of Life Assured Signature of Payer Life/Account Holder

Signature of Joint Life/Second Annuitant/Spouse Signature of Policyholder

Page 7
 ADVICE FEE MANDATE

Applies only to Growth Investment Series, Builder Investment Series, Business Investment Series
(excluding Linked Life Annuities)

PLEASE UPLOAD REQUEST ON BPO AND SEND THIS COMPLETED FORM TO LIBERTY LIFE BY:
• Fax: 011 408 4171 / 3092 OR • E-mail: newbusiness@liberty.co.za

GENERAL DETAILS (to be completed in all instances)

Policy Number:
Policyholder/Member (Full Names):

FINANCIAL ADVISER DETAILS

Financial Adviser Name: Brokerage (if applicable):

Financial Adviser Liberty Life Code:

INVESTMENT ADVICE FEE

I authorise Liberty Life to deduct or facilitate the deduction and payment of the following amounts to cover fees payable to Liberty Life or
another Financial Adviser for advice and other distribution related charges.
Initial Advice Fee (IAF)* Yes No (not applicable to ex CAL policies)
1.14% 3.42% 5.7%
% (Fill in other percentage, up to a maximum of 5% in ¼% increments)
The initial advice fee is a once off fee deducted from the initial consideration at inception on the policy or from the investment value at the
date of extension of the policy.
Ongoing Advice Fee (OAF)* Yes No
0.285% p.a. 0.57% p.a. 1.14% p.a.
% p.a. (Fill on other percentage, up to a maximum of 1% p.a. and in ¼% increments)
Note: OAF can only be applied after the 5th policy anniversary (except for Single Premium Retirement Annuities, Preservers
and the Multiple Access Investment Plans).
The ongoing advice fee is deducted from the investment value as a percentage of the investment value on a monthly basis. If the policy is a
retirement annuity or preserver, this mandate gives the Fund the authority to instruct Liberty Life to reduce the fund member policy by the
value of the fee.
* If these fees are payable to a VAT Vendor, VAT at a rate of 14% will be payable.

CLIENT DECLARATION

1. I understand that I may at any time instruct Liberty Life to stop deducting or deducting and facilitating the payment of any future ongoing
advice fee, alter the amount of any ongoing fee or pay any future ongoing fee to Liberty Life or another Financial Adviser.
2. I understand that any ongoing advice fees agreed to in this mandate may continue to be paid where the Financial Adviser moves
between distribution channels, provided that the Financial Adviser is still contracted to Liberty Life.
3. I understand that my Financial Adviser may work in a Team and therefore any advice fees deducted may be shared with the Team.
4. I agree that this mandate will be automatically renewed on an annual basis unless I instruct Liberty Life to cancel it.
5. I understand that these fees are deducted from the investment value of my policy and will therefore reduce the value of my investment
accordingly.
6. I also understand that any minimum death benefit or investment performance guarantee (where applicable) will be reduced by the
advice fees deducted.

Signature of Policyholder/Member(s)/Authorised Date

Representative/Legal Guardian/Cessionary
NB: Please retain the original documentation to serve as proof of the agreement with your client.

Page 8
 REPLACEMENT POLICY ADVICE RECORD (RPAR)

To be completed in consultation with your intermediary – please note that this does not serve as a cancellation of the replaced
policy; you must advise the insurer in writing about the cancellation of a policy
Name and surname of Policyholder:
ID. Number of Policyholder: (or registration number in the case of non-natural persons)
Name and surname of Intermediary:
Name of FSP (Brokerage or Insurer):
New policy: Type of policy: Investment or risk Policy or proposal number Insurer

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

QUESTION TO THE INTERMEDIARY – TO BE COMPLETED IF THE REPLACED POLICY IS AN INVESTMENT POLICY:

Does this proposal constitute replacement of an investment policy with a recurring premium investment policy that will lead or
Yes No
has led to the levying/deduction of a termination charge of more than 15% of the replaced policy’s fund value? Refer to the
definitions in Part 3 of the Regulations to the Long-Term Insurance Act, 1998 (commission regulations).
1. REASONS WHY REPLACEMENT MAY NOT BE ADVISABLE
If you do replace any policy, we want to ensure that you make an informed choice. Please read the following information, carefully and discuss
with your intermediary.
ƒ 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.
ƒ 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.
ƒ 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.
ƒ Your new policy may not have the same investment performance guarantees as the existing policy (if applicable)
ƒ Your new policy may have more exclusions, restrictions or waiting periods particularly if your health has deteriorated.
ƒ 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.
ƒ You may lose the tax advantage of your existing policy (if applicable).
ƒ The surrender value or paid up value of your existing policy may be as low as 65% 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.
ƒ 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.
2. REASONS FOR THE CHANGE OF POLICY / POLICIES
2.1 Did you establish whether the existing / terminated policy could be amended to provide similar benefits to the replacement policy?
Please print clearly.

2.2 If such amendment is / was possible, why do you regard it as appropriate that the terminated policy be replaced by the replacement
policy? Please print clearly.

3. DECLARATION (COMPULSORY)
INTERMEDIARY POLICYHOLDER
I confirm that I have taken all reasonable steps to confirm that the I confirm that the intermediary has fully explained the consequences of
information in this Replacement Policy Advice Records (RPAR) is the replacement of the policy(ies) mentioned in this Replacement
true and correct. I confirm that in pursuance of my advice to the Policy Advice Record and I understand the consequences of such
policyholder to replace the policy(ies) mentioned in this RPAR. I replacement(s).
have fully discharged my duties as set out in section 8 (d) of the
General Code of Conduct for Authorised Financial Services Contact tel no.
Providers and their Representatives (the Code) and have retained a and / or
record of such advice as required by section 3 of the said Code. e-mail address:
Signature: Signature:
Name: Name:
Date: Date:

Page 9
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 intermediary must complete all the required information.

Initials POLICY DETAILS EXISTING POLICY/IES RECOMMENDED NEW POLICY/IES

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, monthly or single) R R R R

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. Loadings and Excesses (R/%)

11. Restrictions of benefits

12. To what extent are the funds readily realisable?

13. Any vested rights, guarantees or benefits which will be lost?

14. If you were the intermediary on the old product, any
incentive, commission received
15. Tax Implications
16. Why is the replacement product more suitable to the client's
needs?
INTERMEDIARY: I declare that this Replacement Policy Advice Record is an accurate and complete record of the advice and recommendations given that I have given the policyholder.
Name Surname Date Signature
MANAGER:
Name Surname Date Signature
POLICYHOLDER: I declare that this Replacement Policy Advice Record is an accurate and complete record of the advice and recommendations given to me by the intermediary. 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

Page 10
 RISK ANALYSER

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.
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: Note that the best and worst case scenario are equally possible.)
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 policy costs more.
b. Choose a moderate level of excess in order to reduce the premium.
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

1. 15 12 9 1 0 -
2. 0 1 4 8 10 12
3. 0 1 4 10 0 -
4. 0 2 5 10 - -
5. 9 6 3 0 9 -
6. 0 1 5 8 0 -
7. 1 2 8 13 0 -
8. 0 1 4 8 - -
9. 6 10 2 0 - - Total Score
10. 0 1 3 5 - -

Page 11
Investment Portfolio guide
Depending on your score obtained above, your propensity for risk falls into one of the following categories:
Score Risk Profile
Conservative
0 - 25 Conservative Investors are investors who want stability and are more concerned with protecting their current investments
than increasing the real value of their investments
Moderately Conservative
26 - 45 Moderately Conservative investors are investors who want to protect their capital and achieve some real increase in the
value of their investment
Moderate
46 - 65 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
Moderately Aggressive
66 - 85 Moderately Aggressive investors are long-term investors who want real growth on their capital. A fair amount of risk is
acceptable.
Aggressive
86 - 100 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: / /
Name of Liberty Life Financial Adviser
Name of Client Signature of Client
Agree Disagree If disagree, state chosen risk profile:
Growth Investment Series – Portfolio list according to specific risk profile
Moderately
Aggressive Moderately Aggressive Moderate Conservative
Conservative
■ ❍◆ Allan Gray Equity ■ ❍◆ ABSA Balanced Fund ■❍ Excelsior 12 month Top40 ■ ❍◆ ABSA Absolute Fund ■ ❍◆ ABSA Inflation Beater
■ ❍◆ Coronation Equity Fund ■ ❍◆ ABSA International Fund Protector ■ ❍◆ Coronation Balanced Fund
■ ❍◆ Coronation Top Twenty of Funds ■❍ Excelsior 24 month Top40 Defensive Fund ■ ❍◆ Allan Gray Stable
■ ❍◆ Excelsior Aggressive ■ ❍◆ ABSA Select Equity Fund Protector ■ Coronation Income Fund ■ ❍◆ Excelsior Conservative
■ ❍◆ Excelsior Aggressive (C) ■ ❍◆ Allan Gray Balanced ■❍ Excelsior 6 month Top40 ■ Excelsior High Yield ■ ❍◆ Excelsior Conservative (C)
■◆ Excelsior Global Aggressive ■ ❍◆ Coronation Balanced Plus Protector ❍ Excelsior LifeTime ■ ❍◆ Excelsior Conservative
■◆ Excelsior Global Conservative Fund ■ ❍◆ Excelsior Aggressive Income (Phase 2) (C+)
■◆ Excelsior Global Moderate ■ ❍◆ Coronation house view ■ ❍◆ Excelsior Bond ■ ❍◆ Excelsior Managed ❍ Excelsior Conservative (C
■◆ Excelsior Global Moderately ❍ Excelsior Life Time ■ ❍◆ Excelsior CPI Plus Cautious Special Offer)
Aggressive (Phase 4) ■ ❍◆ Excelsior CPI Plus (C) ■ ❍◆ Excelsior Moderately ❍ Excelsior Conservative (C+
■◆ Excelsior Global Moderately ■ ❍◆ Excelsior Managed ■ ❍◆ Excelsior CPI Plus (C+) Conservative Special Offer)
Conservative ❍ Excelsior Managed ❍ Excelsior CPI Plus (C Special ■ ❍◆ Excelsior Moderately ❍ Excelsior Income
■ ❍◆ Excelsior Index 40 (C Special Offer) Offer) Conservative (C) ■ ❍◆ Excelsior LifeTime
■ ❍◆ Excelsior Industrial ❍ Excelsior Managed ❍ Excelsior CPI Plus (C+ ■ ❍◆ Excelsior Moderately (Phase 1)
❍ Excelsior LifeTime (Phase 5) (C+ Special Offer Special Offer) Conservative (C+) ■ ❍◆ Excelsior Multi-Manager
■ ❍◆ Excelsior Multi-Manager Aggressive ■ ❍◆ Excelsior Managed (C) ■ ❍◆ Excelsior Dynamic Return ■ ❍◆ Excelsior Multi-Manager Conservative
■ ❍◆ Excelsior Multi-Manager Aggressive ■ ❍◆ Excelsior Moderately ◆ Excelsior Equity Linked Moderately Conservative ■ ❍◆ Excelsior Multi-Manager
(C) Aggressive Annuity ■ ❍◆ Excelsior Multi-Manager Conservative (C)
■ ❍◆ Excelsior Multi-Manager Equity Fund ■ ❍◆ Excelsior Moderately ■ ❍◆ Excelsior Financials Moderately Conservative ■ ❍◆ Excelsior Multi-Manager
■ ❍◆ Excelsior Nationbuilder Aggressive (C) ❍ Excelsior LifeTime (Phase 3) (C) Conservative (C+)
■ ❍◆ Excelsior Rand Hedge ■ ❍◆ Excelsior Multi-Manager ■ ❍◆ Excelsior Moderate ■ ❍◆ Excelsior Multi-Manager ■ ❍◆ Excelsior Multi-Manager
■ ❍◆ Excelsior Resources Moderately Aggressive ■ ❍◆ Excelsior Moderate (C) Moderately Conservative Income Fund
■ ❍◆ Excelsior Shari’ah Equity ■ ❍◆ Excelsior Multi-Manager ■ ❍◆ Excelsior Moderate (C+) (C+) ■ ❍◆ Excelsior Progressive
■ ❍◆ Excelsior Small Companies Moderately Aggressive (C) ❍ Excelsior Moderate (C ■ ❍◆ Investec Cautious Bonus
■ ❍◆ FutureGrowth Albaraka Equity ■ ❍◆ Excelsior Multi-Manager Special Offer) Managed Fund ■ Noble PP Strategic Income
■ ❍◆ Investec Equity Property Fund ❍ Excelsior Moderate (C+ ■ ❍◆ Nedgroup Investments FoF
■ ◆❑ Liberty Ermitage Aggressive (Euro) ■ Investec High Income Special Offer) Stable Fund ■ ❍◆ Standard Bank Money
■◆ Liberty Ermitage Alpha Class Euro ■ ❍◆ Investec house view ■ ❍◆ Excelsior Multi-Manager ❍ Norwich Guaranteed Fund Market
Fund ■ ❍◆ Investec Managed Bond Fund ■ ❍◆ RMB Conservative Fund
■ ◆❑ Liberty Ermitage Alpha Class Fund ■ ❍◆ Nedgroup Investments ■ ❍◆ Excelsior Multi-Manager CPI
■ ◆❑ Liberty Ermitage Asset Selection Managed Fund Plus
Euro Fund ■ ❍◆ Oasis - Balanced ■ ❍◆ Excelsior Multi-Manager CPI
■ ◆❑ Liberty Ermitage Asset Selection ■ ❍◆ Oasis house view Plus (C)
Fund ■ ❍◆ Old Mutual Balanced A ■ ❍◆ Excelsior Multi-Manager CPI
■ ◆❑ Liberty Ermitage Conservative (Euro) ■ ❍◆ OMAM house view Plus (C+)
■ ◆❑ Liberty Ermitage Euro Money Fund ■ ❍◆ RMBAM house view ■ ❍◆ Excelsior Multi-Manager
■ ◆❑ Liberty Ermitage Global Aggressive ■ ❍◆ RMB Balanced Flexible Property Fund
■ ◆❑ Liberty Ermitage Global Conservative ■ ❍◆ SIM house view ■ ❍◆ Excelsior Multi-Manager
■ ◆❑ Liberty Ermitage Global Moderate ■ ❍◆ STANLIB Quants Fund Moderate
■ ◆❑ Liberty Ermitage Global Moderately ■ ❍◆ STANLIB Balanced Fund ■ ❍◆ Excelsior Multi-Manager
Aggressive Moderate (C)
■ ◆❑ Liberty Ermitage Global Moderately ■ ❍◆ Excelsior Multi-Manager
Conservative Moderate (C+)
■ ◆❑ Liberty Ermitage Moderate (Euro) ■ ❍◆ Excelsior Property
■ ◆❑ Liberty Ermitage Moderately ■ ❍◆ Excelsior Property (C)
Aggressive (Euro) ■ ❍◆ Excelsior Property (C+)
■ ◆❑ Liberty Ermitage Moderately ■ ❍◆ Excelsior Shari’ah Balanced
Conservative (Euro) Fund
■ ◆❑ Liberty Ermitage Sterling Money Fund ❍ Fedsure Guaranteed Fund
■ ◆❑ Liberty Ermitage US Dollar Money ■ Noble PP Balanced FoF
Fund
■ ❍◆ Nedbank Investments Rainmaker
Fund
■ Noble PP Wealth Creator FoF ■ Investment Plan/Investment Plan with Income
■ ❍◆ Oasis Crescent Equity ❑ Offshore Investment Plan
■ ❍◆ Old Mutual Investors A
❍ Retirement Annuity Plan
■ ❍◆ Old Mutual Top Companies A
■ ❍◆ RMB Equity ◆ Living Annuity
■ ◆❑ STANLIB Global Bond Fund
■ ◆❑ STANLIB Global Equity Fund Please check for:
■ ❍◆ STANLIB Gold Fund ● Restrictions and / or availability of portfolios, and
■ ❍◆ STANLIB Wealthbuilder Fund ● Availability of portfolios on Living Annuities for initial considerations of less than R500,000
■ ❍◆ STANLIB Growth Fund

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Builder/Business Investment Series – Portfolio list according to specific risk profile
Moderately
Aggressive Moderately Aggressive Moderate Conservative
Conservative
◊ § LA Allan Gray Equity ◊ § LA ABSA International ◊ § LA ABSA Balanced ◊ § LA ABSA Absolute ◊ § LA ABSA Inflation Beater
◊ § LA Coronation Equity Fund of Funds § LA Coronation house view ◊ § LA Allan Gray Stable Fund
◊ § LA Coronation Top Twenty ◊ § LA ABSA Select Equity ◊ § LA Excelsior Bond ◊ § LA Coronation Balanced ◊ § LA Excelsior Conservative
◊ § LA Ermitage Global Aggressive ◊ § LA Allan Gray Balanced ◊ § LA Excelsior CPI Plus Defensive ◊ § LA Excelsior Conservative
◊ § LA Ermitage Global Conservative ◊ § LA Coronation Balanced ◊ § ø LA Excelsior CPI Plus (C) § LA Excelsior LifeTime (C)
◊ § LA Ermitage Global Moderate Plus ø LA Excelsior CPI Plus (C+) Phase 2 (C) ◊ § LA Excelsior Income
◊ § LA Ermitage Global Moderately § LA Excelsior LifeTime § LA Excelsior CPI Plus (C ◊ § LA Excelsior Managed § LA Excelsior LifeTime
Aggressive Phase 4 Special Offer) Cautious Phase 1 (C)
◊ § LA Ermitage Global Moderately ◊ § LA Excelsior Managed ◊ § LA Excelsior Dynamic Return ◊ § LA Excelsior Moderately ◊ § LA Excelsior Multi-
Conservative ◊ § ø LA Excelsior Managed (C) § LA Excelsior LifeTime Conservative Manager Conservative
◊ § LA Excelsior Aggressive ø LA Excelsior Managed Phase 3 (C) ◊§ LA Excelsior Moderately ◊ § LA Excelsior Multi-
◊ § LA Excelsior Financials (C+) ◊ § LA Excelsior Moderate Conservative (C) Manager Conservative
◊ § LA Excelsior Global Aggressive ◊ § LA Excelsior Moderately ◊ § ø LA Excelsior Moderate (C) § ◊ § LA Excelsior Multi- (C)
◊ § LA Excelsior Global Conservative Aggressive ø LA Excelsior Moderate (C Manager ◊ § LA Excelsior Progressive
◊ § LA Excelsior Global Moderate ◊ § LA Excelsior Multi- Special Offer) Moderately Conservative Bonus
◊ § LA Excelsior Global Moderately Manager Moderately ◊ § ø LA Excelsior Multi-Manager ◊ § LA Excelsior Multi- ◊ § LA Noble PP Strategic
Aggressive Aggressive CPI Plus Manager Moderately Income FoF - A1
◊ § LA Excelsior Global Moderately ◊ § LA Investec Managed ◊ § ø LA Excelsior Multi-Manager Conservative (C) ◊ § LA RMB Conservative
Conservative ◊ § LA Nedgroup Investments CPI Plus (C) ◊ § LA Investec Cautious ◊ § LA Standard Bank
◊ § LA Excelsior Index 40 Managed ø LA Excelsior Multi-Manager Managed Money Market
◊ § LA Excelsior Industrial ◊ § LA Nedgroup Investments CPI Plus (C+)
§ LA Excelsior LifeTime Phase 5 Rainmaker ◊ § LA Excelsior Multi-Manager
◊ § LA Excelsior Multi-Manager ◊ § LA Nedgroup Investments Moderate
Aggressive Stable ◊ § ø LA Excelsior Multi-Manager
◊ § LA Excelsior Nationbuilder ◊ § LA RMB Balanced Moderate (C)
◊ § LA Excelsior Rand Hedge ◊ § LA Excelsior Property
◊ § LA Excelsior Resources ◊ § ø LA Excelsior Property (C)
◊ § LA Excelsior Shari’ah Equity ø LA Excelsior Property (C+)
◊ § LA Excelsior Small Companies ◊ § LA Excelsior Shari’ah
◊ § LA FutureGrowth Albaraka Equity Balanced Fund
◊ § LA Investec Equity ◊ § LA Investec house view
◊ § LA Noble PP Wealth Creator FoF - ◊ § LA Noble PP Balanced FoF -
A1 A1
◊ § LA Oasis Crescent Equity ◊ § LA OMIGSA house view
◊ § LA RMB Equity ◊ § LA Oasis house view
◊ § LA RMBAM house view
◊ § LA SIM house view

◊ Investment Builder / Education Builder

§ Retirement Annuity Builder
ø Investment Linked Repayment Option
Note: Please check for restrictions and/or availability of portfolios.

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