THE DEFERRED VARIABLE ANNUITY

ISLE OF MAN ASSURANCE GROUP THE DEFERRED VARIABLE ANNUITY THE ISLE OF MAN The Isle of Man is situated in the Irish Sea between the United Kingdom an...
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ISLE OF MAN ASSURANCE GROUP

THE DEFERRED VARIABLE ANNUITY

THE ISLE OF MAN The Isle of Man is situated in the Irish Sea between the United Kingdom and Ireland. The total land area is 226 square miles, supporting a population of around 72,000. Over a thousand years ago the Vikings from Norway established the Isle of Man’s supreme legislative assembly, the Tynwald, which survives to this day as the oldest continuous democratic government in the world. Constitutionally therefore, the Isle of Man is not and never has been part of the United Kingdom. The Island remains an independent, self-governing dependency of the Crown with a large degree of autonomy. Since the early 1960’s, Tynwald has nurtured the Island’s financial sector through a legislative policy designed to provide a favourable tax regime coupled with strong regulatory control. Together with a carefully considered economic strategy aimed at long term stability and security and an excellent communications network, these policies have made the Isle of Man one of Europe’s fastest growing and most respected offshore financial centres. The Government maintains a balanced budget and has the power to legislate on all domestic issues, though relying on the UK for foreign policy and defence. The Island is now home to more than 50 licensed banks and over 150 life, general and captive insurance companies. The Isle of Man enacts its own legislation, which is generally based on English Law; hence the rules of English Common Law and the principles of equity are followed by the local courts. Foreign judgements are not binding in the Isle of Man courts.

ISLE OF MAN ASSURANCE GROUP Isle of Man Assurance Limited is the Island’s oldest independent insurance company with over twenty-five years of experience in the offshore marketplace. The Company has a wealth of knowledge in the field of U.S. qualifying life and annuity products, having been involved in the market since the early 1980’s. Part of the Isle of Man Assurance Group of Companies, IOMA is licensed and regulated by the Isle of Man Insurance & Pensions Authority. Isle of Man Financial Trust Limited, an associate Company of the IOMA Group, offers a wide range of offshore corporation and Trust formation and administration services. Isle of Man Insurance Management specialise in risk financing and captive insurance company management.

THE DEFERRED VARIABLE ANNUITY POLICY (DVA) Deferred Variable Annuity (‘DVA’) policies have for many years provided excellent opportunities for tax deferral under U.S. Income Tax Regulations. The interest or capital gains within a DVA are not subject to U.S. tax until actually distributed from the policy. All assets held in the policy therefore are left to accumulate tax-free. IOMA as a tax exempt insurance company incorporated and registered in the Isle of Man, does not suffer taxation on the investment returns obtained through its insurance funds and is also enabled to make distributions to Policyholders free of any Isle of Man taxes. IOMA’s DVA is a single premium contract with a Minimum Premium of $100,000. Additional Premiums (subject to a minimum of $20,000) may be paid subsequent to Policy issue. (There is no limitation on the maximum premium). The policy is designated to meet the requirements of Sections 72 and 817 of the United States Internal Revenue Code 1986, as amended. The Policy provides for an annual annuity benefit to be payable during the lifetime of the Annuitant, as from the date selected by the Policyholder, not sooner than the Annuitant's 60th birthday subject to the exceptions outlined below. Annuity payments will be calculated in accordance with the appropriate mortality tables used by the Company at the annuity start date, or as may be otherwise agreed. As the amount of the annuity payment each year will be influenced by the value of the retained assets under the policy the contract is classified as a DVA under the terms of the U.S. Internal Revenue Code. In the event of the death of the Annuitant prior to full distribution of the accumulated assets under the policy by way of annuity payments, any residual value will be paid to the Beneficiary, or the Policyholder, if no Beneficiary has been nominated or survives. A death benefit is payable upon the death of the Policyholder before the annuity start date equal to the accumulated asset value of the policy. Also, the policy can be surrendered without penalty (other than a possible tax penalty described below) at any time before the annuity start date. The tax treatment of the death benefit and surrender proceeds received in the United States is different to that applicable to annuity benefit payments. Under U.S. Tax Regulations other important considerations exist, namely: The Annuity (with some exceptions) must be held by an individual or a trust or an agent for an individual or natural person; Any distribution from an annuity contract is subject to 10% tax penalty unless the distribution is made: (a) on or after the date the Annuitant reaches the age of 59½; (b) because of the Annuitant’s disability; (c) on or after the death of the Annuitant; (d) under an immediate annuity contract; (e) under certain contracts specified under the IRS Regulations.

SECURITY OF ASSETS Under Isle of Man law, all premiums paid into life or annuity policies must be held in a “Long Term Business Fund”, segregated from all other business transacted by the Company. The assets under this fund are solely for the benefit of the Company’s life and annuity policyholders and cannot be used to meet claims from other policyholders or general creditors, in the event of the Company’s insolvency. Life and annuity policies issued in the Isle of Man after April 5, 1988, are protected by the Life Assurance (Compensation of Policyholders) Regulations 1991, which provide a statutory guarantee equal to 90% of the amount of any liability the Life Company may have under a life assurance or annuity contract.

INVESTMENT OPPORTUNITIES Investment Option 1 - IOMA’s Funds Isle of Man Assurance Limited offers a comprehensive range of Investment Funds enabling you to construct a diversified portfolio within the DVA to meet your own risk/reward profile. We adopt a multi-manager approach, employing leading asset managers in each particular market sector. Our independent status enables us to identify specialist managers in a variety of fields, constantly monitor performance and re-allocate assets between managers where we consider appropriate. We are not tied to any one investment house. The Funds are no-load and Policyholders may switch between the Funds on a monthly basis without charge. Fund Name

Benchmark Index

Equity Funds United States Growth United Kingdom Growth European Growth Japan Growth Emerging Market Growth Gold Biotechnology Index Funds S&P 500 Dow Jones Industrials Hedge Funds Safety First IOMA Diversified Cash Reserve Money Market Funds United States Dollar Cash Reserve British Pound Cash Reserve Euro Cash Reserve Swiss Franc Cash Reserve Japanese Yen Cash Reserve New Zealand Dollar Cash Reserve

Currency

S & P 500 FTSE All Share MSCI Europe ex UK Nikkei 225 ING Baring Emerging XAU

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ GBP EURO CHF JPY NZD

Performance statistics are available from on our website at

www.ioma.co.im

Investment Option 2 – Independent Investment Manager Policyholders may request IOMA to appoint an independent Investment Manager to manage the investment portfolio held within the policy. The Manager must undertake to comply with section 817(h) concerning diversification of assets, and must also be approved by IOMA.

THE ADVANTAGES OF TAX DEFERRAL Grow th in Millions

Years

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

2

4

6

8

Tax Def erred Account Tax Payable at 45%

Please note: The illustration above is based on an initial investment of US$1,000,000 and assumes a net annual return after fees of 10%. The taxable account values are based on a short term capital gains tax rate of 45%.

FREQUENTLY ASKED QUESTIONS Q. A.

What are the advantages of the DVA Policy over a policy issued by a U.S. domiciled insurance company? IOMA is not subject to any form of taxation on Policyholder funds. Also, no domestic premium taxes are payable in the Isle of Man. IOMA offers a high level of privacy. There are no reporting requirements to any authorities, and IOMA is not required to file 1099 forms. Distributions from the Policy are not taxable by the Isle of Man Government.

Q. A.

How secure are my funds with Isle of Man Assurance Limited? Under Isle of Man law, all premiums paid to a life insurance company under an annuity policy must be held in a “Long Term Business Fund”, segregated from all other business transacted by the Company. The assets under this Fund are solely for the benefit of the Company’s Life Policyholders and cannot be used to meet claims from Policyholders or general creditors. In the event of the Company’s insolvency, the Life Assurance (Compensation of Policyholders) Regulations 1991 provide a statutory guarantee equal to 90% of the amount of any liability of the insurance company under any life or annuity policy.

Q. A.

Do I have to be insurable? No. A DVA is not life insurance, no additional death benefit is payable.

Q. A.

Is my Policy protected against creditors? Any claim by creditors of the Policyholder can only be made through the courts in the Isle of Man

Q. A.

What are my investment options? You may choose between any of our Investment Funds listed in the brochure, or you may request IOMA to appoint an approved independent Investment Manager to manage your account. Any such Manager must be approved by IOMA.

Q. A.

What about Hedge Funds? IOMA have established links with several offshore Hedge Funds. We allow access to these Funds via the DVA, but only to audited Hedge Funds.

Q. A.

How often can I switch between your Funds and what does it cost? You may switch between our Funds on a monthly basis at your discretion without charge.

Q A.

What are my reporting requirements to the IRS? Income credited to annuity contracts whilst in place is not generally includable as income under individual tax returns. As long as the Policy is in place, all increases in the value of the underlying investments, interest and divided income will be free of U.S. income tax.

Q. A.

What about Federal Excise Tax? Federal Excise Tax of 1% is imposed by the United States Government on premiums paid into policies issued by foreign insurers and Form 720 should be filed with the Internal Revenue Service. If there is any doubt about the payment of Excise Tax you should consult your tax advisor. As a comparison State Insurance Premium Tax can be as high as 5.0%.

Q. A.

Is there any tax payable in the Isle of Man? No.

Q. A.

What currencies can I invest in? Our Funds are generally denominated in US$. (They do however, invest in other currencies in their own right). Our Cash Reserve Funds are available in US$, GBP, EURO, CHF, JPY and NZ$.

Q. A.

How often do I receive valuations of my Policy? We provide quarterly valuations for our Policyholders. These summarise the investment portfolio of each Policy and are mailed or emailed shortly after the end of March, June, September and December.

Q. A.

Am I required to keep the Policy in place for a certain period of time? No. You may make a partial or total surrender from your Policy at any time. IOMA does not levy any penalty charge for surrender, but a U.S. tax penalty may be imposed in certain circumstances.

Q. A.

What taxes are payable on withdrawals? Withdrawals are taxed at the Federal level at ordinary income rates.

ANNUITY PAYMENT OPTIONS We are able to offer four flexible annuity payment options with the DVA. Option 1.

Annuity for an agreed period You specify the number of years over which you would like to receive annuity payments.

Option 2.

Annuity for life with an agreed guaranteed term We can offer this option over 10 or 20 years. We will continue to pay the annuity over the remainder of the guaranteed term in the event of the death of the annuitant.

Option 3.

Life Annuity Payments will be made from the chosen annuity start date throughout the lifetime of the annuitant.

Option 4.

Joint and Survivor Annuity Payments will be made throughout the lifetime of two Annuitants. Payments only ceasing upon the death of the second Annuitant. Policyholders may select one of the four options at any time not less than 30 days from the date of the first annuity payment.

POLICY CHARGES Initial Charge:

1% of premiums paid or $5,000 whichever is greater.

Annual Management Charge: If invested in IOMA Funds: If invested with an independent Investment Manager

1.5% per annum 1.0% per annum (plus Manager’s fees)

Please note: IOMA does not levy additional charges for transactions, valuations or full or partial cash surrenders. Federal Excise Tax of 1% is imposed by the United States Government on premiums paid into policies issued by foreign insurers and Form 720 should be filed with the Internal Revenue Service. If there is any doubt about the payment of Excise Tax you should consult your tax advisor.

HOW TO APPLY To apply for a Deferred Variable Annuity Policy with IOMA, please:1.

Complete and provide the following:Please tick (a) •

DVA Application Forms



Read and sign the Important Notes form



Personal Financial Questionnaire (Required if single premium exceeds US$250,000) Proof of age and identification for all persons included on the Application i.e.notarized copy of Birth Certificate or Passport)

• 2.

Forward the above by mail to:Isle of Man Assurance Limited, IOMA House, Hope Street, Douglas, Isle of Man, IM1 1AP, British Isles You may fax your application forms to 011 44 1624 681344 with the originals to follow by mail.

3.

Your premium should be transferred by wire transfer to:Bank of New York, New York Swift Code IRVTUS3N ABA No: 021 000 018 Account: Euroclear Account No: 890-0405-139 In favour of Matheson Investment International Limited A/c No: 94107 Reference: Isle of Man Assurance Premium Income C4430 Further Ref: DVA Premium Alternatively you may forward a cheque or bank draft with your application forms, made payable to “Isle of Man Assurance Limited A/C DVA”.

IMPORTANT NOTES Before deciding to make an application for the issuance of an annuity policy, it is important that you are made aware of recent developments in the United States federal income tax laws and regulations with respect to annuity contracts issued to persons subject to U.S. federal income tax by insurance companies that do not do business in the United States. Investment earnings under deferred annuity contracts owned by or on behalf of individuals are not taxed until they are distributed, subject to the considerations discussed below. The primary requirement for a contract to qualify under U.S. tax rules as an “annuity contract” and thus offer tax deferral on investment earnings, is that the contract must meet all of the conditions of Section 72 of the Internal Revenue Code of 1986, as amended (the “Code”), and regulations and rulings under Section 72. Following advice received from its U.S. Attorneys, IOMA is satisfied that the Deferred Variable Annuity (“DVA”) does comply with these rules. There are further requirements applicable to the diversification of investments underlying “variable contracts” (that term is defined in Section 817(d) of the Code to include variable annuities and variable life insurance contracts) that are detailed under Section 817 (h) of the Code and the regulations thereunder (the “diversification rules”). A variable annuity contract that meets the requirements of Section 72 will not be treated as an annuity contract for federal income tax purposes unless it also complies with the diversification rules. Under the diversification rules, the investments of every “segregated asset account” underlying any variable annuity must be “adequately diversified”. The U.S. Treasury Department and Internal Revenue Service (the “IRS”) have issued regulations that prescribe standards for determining whether the investments of a segregated asset account are “adequately diversified” IOMA believes that the DVA is subject to the diversification rules. If any Unitized Investment Fund upon which a DVA is based fails to comply with these diversification standards, a U.S. taxpayer who is the Owner of such DVA would be subject to tax currently on annual increases in value of the DVA. [Although IOMA does not control the investments of the Funds upon which the DVA is based.] it will use commercially reasonable efforts to cause [the managers of] the Funds to comply with the diversification rules. [IOMA cannot give any undertakings or guarantees with respect to the possible application of the diversification rules in the event that you chose to take delivery of an DVA] In addition to the diversification rules, the IRS has published revenue rulings (the “Investor Control Rulings”) setting forth circumstances in which the owner of a variable contract, rather than the insurance company that issued the contract, will be treated as the owner, for U.S. federal income tax purposes, of the assets held in the segregated asset account that supports the variable contract. IOMA has implemented procedures that are intended to cause the Owner of an DVA to comply with the Investor Control Rulings. Such compliance is the responsibility of the Owner, however, and no assurance can be given that the IRS will not assert in certain situations that the Owner of an DVA is the owner of assets of a Fund for U.S. federal income tax purposes. Despite compliance with the rules of Section 72, as well as the diversification rules and Investor Control Rulings, annuity contracts issued by insurance companies that are not subject to U.S. corporate income tax on their insurance income are potentially subject to treatment as “debt instruments” under the “original issue discount” (“OID”) rules of Section rules of Section 1271 et seq. of the Code. If the OID rules apply, undistributed investment earnings with respect to the annuity would be includible in the gross income of a U.S. taxpayer annually on an accrual basis. The OID rules are not, however, applicable to annuities that meet one of two exceptions to the definition of the term debt instrument set out in Section 1275 of the Code. One such exception applies to annuities that are based in whole or in substantial part on the life or life expectancy of one or more individuals. The other exception applies to annuities issued “by an insurance company subject to tax under Subchapter L (or by an entity described in Section 501 (c) and exempt from tax under Section 501 (a) which would be subject to tax under subchapter L were it not so exempt”. Subchapter L contains the provisions of the Code that apply to insurance companies, and Section 501 relates to certain tax-exempt entities. With respect to the first exception, Treasury Regulation§1.1275-1 (j) sets out specific provisions an annuity contract must contain in order to come under this exception. The DVA would generally not meet the requirements of these regulations. With respect to the second exception, recent legislation, as well as proposed regulations, may if the regulations are finally adopted, cause certain annuity contracts issued by insurance companies that are not subject to U.S. federal income tax on their business profits (and are not tax-exempt entities) to be treated as debt instruments. In December of 2001 Congress adopted a “technical correction” of section 1275(a)(1)(B)(ii) that added the reference to tax exempt entities (effective retroactively to 1984, the original date of enactment of section 1275). The IRS subsequently issued proposed regulations that, if adopted, would clarify that annuities issued by foreign insurance companies that are not subject to U.S. corporate income tax on their insurance income are subject to the OID rules (effective for annuities issued on or after January12, 2001). IOMA is not subject to United States tax on its corporate income and thus the exception for annuities issued by insurance companies “subject to tax under subchapter L” is not applicable to the DVA. Because the DVA is variable in nature, however, the impact of the recent legislation and proposed regulations is not clear. Existing regulations (Treasury Regulations § 1.1275-1(d) provides that the term debt instrument, for purposes of the OID rules, includes only instruments that are debt instruments “under general principles of Federal income tax law”. Whether and in what circumstances a variable annuity such as the DVA would be treated as a debt instrument under general principles of federal tax law is not addressed by the regulations. IOMA CANNOT GIVE ANY UNDERTAKINGS OR GUARANTEES WITH RESPECT TO THE POSSIBLE APPLICATION OF THE OID RULES, AS WELL AS THE DIVERSIFICATION RULES OR INVESTOR CONTROL RULINGS. THE PURCHASER ASSUMES ALL RISK THAT THE TREATMENT UNDER THE CODE OF THE DVA WILL BE LESS FAVORABLE THAN ANTICIPATED. IOMA STRONGLY RECOMMENDS THAT ANY DECISION YOU MAKE SHALL BE FULLY INFORMED.

DECLARATION TO BE SIGNED BY THE APPLICANT(S) I/We have read and understood the above information and I/we would like to apply for an Isle of Man Assurance Limited Deferred Variable Annuity Policy. Signature of Applicant(s)

Date (Day/month/year)

Signature of Annuitant(s)

Date (Day/month/year)

Please also complete the following forms

A. DETAILS OF THE APPLICANT(S) First or Sole Applicant

Joint Applicant (if any)

Title (Mr/Mrs/Miss/Other) Last Name(s) First Name(s) Mailing Address

ZIP

ZIP

ZIP

ZIP

Telephone Number Fax No E-mail Address Correspondence Address if different from above.

Date of Birth (Day/Month/Year) Sex

Male

Female

Male

Female

Is the Applicant to be an Annuitant?

Yes

No

Yes

No

Passport or National Identity card number Certified copies of passport(s)/identity card(s) should be enclosed for all persons mentioned on the application form. B. DETAILS OF THE ANNUITANT (if different from the Applicant(s))

First or Sole Annuitant

Joint Annuitant (if any)

Title (Mr/Mrs/Miss/Other) Full Forename(s) Surname Date of Birth (Day/month/year) Relationship to applicant C. BENEFICIARY DETAILS Beneficiary to whom any Death Benefit shall become payable Policyholder/ Policyholder’s Estate Other, as per the following instructions

Annuitant

D. ANNUITY PAYMENT DATES Annuity Start Date Frequency of Annuity Payments

Specify:

Quarterly

Semiannual

Annual

E. PREMIUM DETAILS Total investment to the Annuity

US$

Less Initial Fees

US$

Balance to be invested

US$

(minimum premium US$100,000)

F. INVESTMENT OPTIONS Fund Name Equity Funds United States Growth United Kingdom Growth European Growth Japan Growth Emerging Market Growth Gold Biotechnology Index Funds S&P 500 Dow Jones Industrials Hedge Funds Safety First IOMA Diversified United States Industry Sector Fund Cash Reserve Money Market Funds United States Dollar Cash Reserve British Pound Cash Reserve Euro Cash Reserve Swiss Franc Cash Reserve Japanese Yen Cash Reserve New Zealand Dollar Cash Reserve Total Allocation of Premium

Benchmark Index S & P 500 FTSE All Share MSCI Europe ex UK Nikkei 225 ING Baring Emerging XAU

Currency

% Allocation of Premium

US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ US$ GBP EURO CHF JPY NZD 100%

If you would like to appoint an independent Investment Manager, please check this box and give details on the attached Form G. DECLARATION AND APPLICATION I/We hereby declare that to the best of my/our knowledge and belief, the particulars contained herein are true and complete and I/We agree that the Application containing this Declaration, (together with any other written statements or declarations made in connection with this Application), shall form the basis of the contract between myself/ourselves and Isle of Man Assurance Limited (‘IOMA’). I/We have read the brochure relating to the DVA and that we have read and understood the Important Notes Section of the DVA brochure offered by IOMA and understand the provisions thereof. I/We have satisfied myself/ourselves that there are no legislative, exchange control or other regulations to which I/we are subject which would prohibit the effecting of this annuity contract I we understand and accept that IOMA cannot be held responsible for the investment performance of the DVA. I/We understand that the value of investments can go down as well as up. I/we authorise IOMA to accept instructions by electronic means (E-mail or Facsimile) from me/us or my/our financial adviser. I/We understand and accept that IOMA is not and will not be responsible or liable in respect of any personal liability to taxation arising in consequence of me/us effecting this Annuity Contract. In addition, I/we understand and accept the consequences and obligations imposed by the United States Internal Revenue Code as amended. I/We declare that entry into this contract is made without solicitation from IOMA or any representative thereof. I/We confirm that I/we am/are not a resident of the Isle of Man and that to the best of my/our knowledge and belief are not subject to any taxation, exchange control or legislation that would make this application unlawful. DATA PROTECTION I/We consent that any personal information obtained by IOMA (whether contained in this Application or otherwise and whether stored electronically or otherwise) may be held and used or disclosed to enable IOMA to process this Application or any subsequent transactions and to communicate with me/us whether directly or indirectly for any purpose.

Signature of Applicant(s)

Date (day/month/year)

Signature of Annuitant(s)

Date (day/month/year)

Policy Number

ISLE OF MAN ASSURANCE LIMITED APPOINTMENT OF INVESTMENT MANAGER

Name of Investment Advisory Company Individual/Contact Name Address

Telephone

Fax

E-Mail

POLICY NUMBER I/We request the appointment of the above named independent Investment Manager to the above referenced Policy in accordance with the terms and conditions specified below. I/We understand that Isle of Man Assurance Limited ("the Company") shall not be liable for any loss caused to the Policy or its value howsoever arising as a consequence of the Company following advice given by, or the negligence of, the above Investment Manager. I/We authorise all Investment Management Fees to be deducted from the Policy Account by the Investment Manager in accordance with the following terms: Annual Investment Management Fee

Additional Fee Provisions

Signed

Policyholder

Date

Signed

Joint Policyholder (if applicable)

Date

The Investment Manager may make investment recommendations for the above Policy to purchase or sell assets subject to the following terms and conditions: 1.

The Investment Manager shall be responsible for ensuring compliance of the investment portfolio of the Policy, with the 'Diversification of Assets' rules as laid down in IRS Code 817 (h) namely; (a) No more than 55% of the value of the total assets of the account can be represented by any one investment. (b) No more than 70% of the value of the total assets of the account can be represented by any two investments. (c) No more than 80% of the value of the total assets of the account can be represented by any three investments. (d) No more than 90% of the value of the total assets of the account can be represented by any four investments.

2.

All assets recommended shall either be quoted on a Stock Exchange recognised by the Company or specifically agreed by the Company as eligible to be purchased by the Policy.

3.

The Company retains the right to reject or accept advice given by the Investment Manager at its absolute discretion and without any liability to the Policyholder whatsoever.

4.

Any assets purchased as a result of a recommendation received from the Investment Manager shall be purchased at the open market buying price as shown on the contract note issued by the vendor or stockbroker and designation of the above referenced Policy number.

5.

All assets are held in the name of the Company. All dealing and contract notes must be made and rendered in the name of the Company and above referenced Policy number.

6.

This Agreement may be terminated by either party at any time by giving written notice.

7.

The Company reserves the right to cancel this Agreement without having to assign any reason. In the event of the death, bankruptcy or insolvency of the Investment Manager or any composition with creditors, this Agreement shall terminate forthwith, without notice.

8.

This Agreement shall be construed and take effect in accordance with the laws of the Isle of Man and the parties shall, in the event of any dispute, irrevocably submit to the jurisdiction of the Manx Courts.

9.

This Agreement applies to the above referenced Isle of Man Assurance Limited Policy only.

Signed

Date Investment Manager

Signed

Date For and on behalf of Isle of Man Assurance Limited

ISLE OF MAN ASSURANCE LIMITED TO BE COMPLETED BY POLICYHOLDER IF SINGLE PREMIUM EXCEEDS US$250,000 (or currency equivalent) PERSONAL FINANCIAL QUESTIONNAIRE (SOURCE OF FUNDS) Relating to the application for a Deferred Variable Annuity Policy

FULL NAME(S):

DATE OF BIRTH

OCCUPATION: ADDRESS: BANK DETAILS:

1. Please state the Policyholder’s annual income for the last 3 years YEAR _ _ _ _

YEAR _ _ _ _

YEAR _ _ _ _

(a) From own trade: (b) From investments: (c) From other sources:

2. Please detail Policyholder’s liabilities (eg. Mortgage and Loans)

3. Please give details of dependents (number, age and relationship)

4. Has the Policyholder ever been declared bankrupt? (If yes, please give details and dates)

/continued overleaf ……… Page 1 of 2

PERSONAL FINANCIAL QUESTIONNAIRE (continued) Relating to the application for a Deferred Variable Annuity Policy 5. Where the Annuitant is different from the Policyholder what is the relationship?

6. Please give details of personal assets (excluding life assurance) Fixed Property:

US$

Investments:

US$

Other Assets:

US$

Total Assets:

US$

Total Liabilities:

US$

Total Estimated Net Worth:

US$ ___________________________________

7. What is the source of the funds to be invested (ie. investments, income, borrowing)

I declare that the above statements are true and correct and form part of my proposal for an Annuity policy. I understand that failure to give true and complete answers to all questions may entitle the Company to reject a claim made under the Policy. Signed:

Date: (Policyholder)

I confirm that the above statements are true and correct. Signed:

Date: (Independent Professional third party)

Occupation: Qualifications:

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