| TRANSAMERICA Life Insurance Application

LIFE BERMUDA LTD Part 1

WARNIN URSUANT TO SECTION 25(5) OF THE INSURANCE ACT CAP 142, YOU ARE FO DISCLOSE IN RESPECT OF THIS APPLICATION, FULLY
AND FAITHFULLY, ALL FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE THE POLICY ISSUED MAY BE VOID.

Proposed Insured Details

1. Surname/Family Name 2. Given Name 3. Gender

Male | Female
4. Date of Birth 5. Age Last
Month Day Year Birthday 6, NRIC/Passpart No. 7. Country of Issuance

8. Country of Citizenship 9. tf you are a Citizen of Singapore, have you resided in Singapore at any time during the past five years?
Yes No

If you are currently residing in Singapore, but NOT a Citizen of Singapore. please complete questions 10 and 11.
10. Please select one of the following checkboxes:
[i] am a Permanent Resident of Singapore
i || hold a work pass or permit required under the Singapore Employment of Foreign Manpower Act (Cap. 914)
| |) hold a pass or permit required under the Singapore tmmigration Act (Cap. 133) that has a duration of longer than 90 days

11. How Jong have you been residing in Singapore in the immediate past 12 months?

1 11-90 days
(191 - 182 days
[2183 days
12. Occupation 13. Employer 14. Annual Earned Income
USS
15. industry/Duties 16. Employer Address 17. Employer Telephone
18, Residential Address Postal Code

18a. How Jong have you resided in the country listed in 18?

18b. If your response to 18a was less than 3 years, please tist all of your countries of residence for the past 3 years.

19. Correspondence Address sit difterent ham anova} Postal Code

20. Telephone (Home) (Work) (Mobile) 21. E-mail Address

Transamerica Life (Bermuda) Ltd.
o 8

Singapore Branch Office. 1 Finlayson Green #13-00, Singapore 049246 I
APA 40SG-0611 1of8 * DT O *

Co. Reg. No. TOSFC6768E

Proposed Owner Details (if other than Proposed insured)

22. Owner Type

Individual | Corporation Trust, dated

Partnership | Other. describe

GST Registered
Yes GST Registration No.

gwidual.
23. Surname/Family Name 24. Given Name 25. Relationship to Proposed Insured
27. Date of Birth
26. Gender Month Day Year 28. NRIC/Passport No 29. Country of Issuance
Male Female | |
30. Country of Citizenship 31. It you are a Citizen of Singapore, have you resided in Singapore at any time during the past five years?
Yes No

Tryou are currently residing in Singapore, but NOT a Citizen of Singapore, please complete questions 32 and 33.
32. Please select one of the following checkboxes:
“jam a Permanent Resident of Singapore
‘] hold a work pass or permit under the Singapore Emptoyment of Foreign Manpower Act (Cap. 91A)
'{ hold a pass or permit under the Singapore Immigration Act (Cap. 133) that has a duration of longer than 90 days

33. How long have you been residing in Singapore in the immediate past 12 months?
1-90 days
91 ~- 182 days

34. Residential Address Postal Code

35. Correspondence Address (i different trom above} Postal Code

36, Telephone (Home) (Work) (Mobile) 37. E-mail Address

If Entity: (i.e. partnership, corporation, trust, other)
38. Full Name 39. Entity ID 40. Country of Domicile

41. Registered Address Postal Code

42. Correspondence Address {if aifferent trom above) Postai Code

43. Telephone

MO

APA 408G-0611 20f8 * DT O *
Beneficiary Information

44, If individual(s): (If other than immediate family member, provide insurable interest in Remarks.)

Full Name Address Share* (%) Relationship to
Proposed Insured

a. NMY(IES) (1.6. ParNersnip, COPPOFATION, trust. OINCE,
Fait Name Address Share* (%) Relationship ta Date of Trust
Proposed Insured (if applicable)

“If more than one Beneficiary is named, payment will be made in equal shares to the surviving beneficiaries. unless otherwise indicated. Any policy issued based upon
this Application will be subject to Bermuda law. Your beneficiary may be changed at any time unless you specifically direct us otherwise. If you are interested in making
a beneficiary designation that cannot be changed, you can designate an irrevocable beneficiary. Once an irrevocable beneficiary designation has been made, it cannot be
changed without the irrevecable beneficiary's written consent.

Details of Insurance Applied For

46, Plan Applied For Pian Code

47. Face Amount Applied For
USS

48, Risk Class Applied For (Standard Risk Class Unless Otherwise Indicated)

Rating «i appiicabie)

49. Additional Benetits Amount Applied For

Term Conversion Rider
Waiver of Premium/Waiver Provision Rider

Accident Indemnity Rider US$

Surrender Penalty Deferral Endorsement

Other USS

50. Premium Payment Mode

Annual | Semi-Annuat _ Quarterly Monthly

Premium Payment Method
Wire/TT | Bank Draft | Check

54, For Flexible Premium Plans
Required Premium Per Year (RAP) | uss

Planned Periodic Premium (PPP) uss | Years
+ Initial Lump Sum | USS |
=Total Initial Premium |uss |

DO NOT PAY ANY PREMIUM WITH THIS APPLICATION.

52. if the Automatic Premium Loan Provision is available, it is to be
Effective Not Effective

0

APA 40SG-0611 3o0f 8
53. Mail Additional Premium Notices To {Address} yt

For the following questions, “you” means the person proposed te be insured.

54.

55.

56.

5

58.

60.

6

62.

63.

6.

65.

MN

>

Do you plan to travel to locations outside Singapore, Hong Kong, Taiwan, Japan,
Australia, New Zealand. the U.S., Canada or Western Europe, for business or teisure.
within the next 24 months? If ‘Yes", complete Foreign Nationals & Foreign

Travel Questionnaire.

In the past two years. have you participated in aeronautics. power racing of
competitive vehicles, skin or scuba diving, mountain climbing, rodeos or
competitive skiing? If Yes". complete Sports and Avocation Questionnaire.

Have you used nicotine at any time?
a. Cigarettes
b. Cigar/Pipe

Do you intend to fly other than as a passenger or have you flown other than as
a passenger during past two years? If "Yes', complete Aviation Questionnaire.

Have you ever been convicted of a criminal act? If Yes", give full details in Remarks.

. Are you a member of the armed forces. inctuding reserves? Do you intend to

become a member? (f *Yes", give full details in Remarks

In the past five years, have you been convicted of or pleaded guilty to any
driving violations. If "Yes", provide dates and type.

. Total Life Insurance you have In Force with atl Companies Company

Business

Yes

Yes

Yes
Yes

Yes

Yes

Yes

Yes

Na

No

No
No

No

No

No

USS

Date Last Used/Quantity

Issue Year

Personal

Accidental Death Insurance

Waiver of Premium/Waiver Provision Coverage

Has any company declined to issue, reinstate or renew: rated, modified, postponed or
cancelled, any life insurance on you? If "Yes", please provide details.

Do you have any applications for life insurance pending with any other
companies? If ‘Yes’. provide all details including company names, amounts
applied for and total amounts to be placed.

Yes

Yes

No

No

Is this Application to replace or intended to replace any policy or policies with
this or any other company? If "Yes". provide all details including names of
companies, policy numbers and amounts to be replaced.

Do you have any undischarged bankruptcy at this time?
lf Yes", please state type & details.

APA 408G-0611 40f8

Yes

Yes

No

No

IMAI
66. Financial Statement (Personal Insurance Onty}
Complete the following if the face amount applied for is between US$1,000,001 and US$5,000,900.
(Complete the Personal Financial Supptement if the face amount exceeds US$5,000,000.)
Purpose of Insurance
£1 Income Replacement
| Estate Planning

TC Protection for Dependents

Proposed Insured Employment information

Commencement Date of Employment: (mmidd/yyyy)

Percentage of employer shares owned:

Proposed Insured Financial Information

Annual income

USS Current Year Last Year
Annual Earned Income

Bonuses

Total income

Assets

LS) Current Year Last Year
Cash
Other Assets

Total Assets

Liabilities

USS Current Year Last Year

Types of liabilities e.g. Mortgage

Total Liabilities

Estimated net worth USS:

APA 4086-0611 Page 5 of 8

WARNING: It is usually disadvantageous to replace an existing life insurance policy with a new one. Some of the disadvantages are:

{i) you may not be insurable on standard terms;

{ii) you may have to pay a higher premium in view of higher age;

(iii) this may result in iosing the financial benefits accumulated over the years.

In your own interest, we would advise that you consult your present insurer before making a final decision. Hear fram both sides and make a careful comparison.
You should be sure that you are making a decision that is in your best interest.

Remarks: Give details if you have answered ‘Yes’ ta any of the above questions.

a

APA 408G-0611 6ot8
|, the Proposed Insured, and I, the Proposed Owner (if different}, hereby represent
that the statements and answers given in this Application are true. complete and
correctly recorded.

|, the Proposed Insured, and I, the Proposed Owner (if different), agree:

{1} This Application shall consist of Part 1, Part 2, and any required Application
Supplement(s), and shall be the basis for any policy issued on this Application;
(2) Life insurance coverage on this Application shall not take effect until after alt
of the following conditions have been met:
{a) Part 1 and Part 2 of the Application, and all medical examinations, tests.
screenings and questionnaires required by Transamerica Life (Bermuda) Ltd.
(‘the Company") are completed and received at our Branch Oftice in satisfactory
condition;
(b) The Company has communicated to the Proposed Ovmer that the policy
has been approved for issue, and if approved other than as applied for, the
Company has received the Proposed Owner's written acceptance at its
Branch Office;
(c) The Company has received the full initial premium at its Branch Office
during the lifetime of and while the Proposed Insured is in good health; and
(d) All the statements and answers given in this Application are true, complete
and have not changed as of the date of the Company's receipt of the full initial

premium at its Branch Office.
No premium shall he paid or accepted before the Company requests fin writing,

|, the Proposed Insured, hereby authorize any physician, medical practitioner.
hospital, clinic, other medical or medically related facility, insuring or reinsuring
company. consumer reporting agency, or employer having information available as
to testing. diagnosis, treatment and prognosis with respect to any physical or mental
and/or treatment of me and any non-medical information of me to give the Company
or its legal representative, any and all such information.

I, the Proposed Insured, and |, the Proposed Owner (if different), understand the
information obtained by use of the Authorization will be used by the Company to
determine eligibility for insurance and eligibility for benefits under an existing policy,
Any information obtained will not be released by the Company to any person or

organization except to reinsuring companies or other persons or organizations
performing business or legal services in connection to my Application, claim ar
may be otherwise lawfully required or as | may authorize

Declaration & Authorization to Obtain Informati

(4) No waiver or modification shall be binding upon the Company unless in writing
and signed by its Chief Executive or a Vice President and Secretary or an

(5) A copy of the Benefits Illustration, Product Summary, and Fact Find (if
applicable) has been provided. The contents of these documents have been
explained to my satisfaction, and | have read and understood them;

(6) | have been infarmed and directed to view or download a copy of Your Guide
to Life Insurance from www.transamerica.com.sg or www. lia.org.sg: and

{7} 1 have read the Section 25 (5) Insurance Act (Cap. 142) warning stated on
the front of this Application form.

|, the Proposed Insured, and |, the Proposed Owner (if different), understand that
omissions or misstatements in this Application could cause an otherwise valid
claim to be denied under any policy issued from this Application.

ifa material fact is not disclosed in this Application, any policy issued may not be
valid. {f you are in doubt as to whether a fact is material. you are advised to
disclose it. This includes any information which you may have provided to the
insurance representative but was not included in this Application. Please check to
ensure you are fully satisfied with the information deciared in this Application.

1, the Proposed Insured, and |, the Proposed Owner (if different), know that
| may request to receive a copy of this Authorization. |, the Proposed Insured,
and I, the Proposed Owner (if different), agree that a photocopy of this
Authorization shall be valid as the original. 1, the Proposed Insured, and |,

the Proposed Owner (if different), agree this Authorization shall be vatid for two
and one half years from the date shown below,regardless of my condition and
whether living or deceased.

Note: If information is to be released by a person or facility located in the U.S.,
the Authorization for Release and Disclosure of Health Related Information form
must be completed and attached.

Consent To Being Insured

|, the Proposed Insured, hereby irrevocably give my written consent to the purchase by the Proposed Owner, of a life insurance policy on my life from Transamerica Life

(Bermuda) Ltd.

The governing law of the policy applied for will be the laws of Bermuda and all parties agree to comply with all laws and regulations applicable under it.

U.S. Tax Information

The Proposed Insured and the Proposed Owner each represents and warrants that he/she/it is not a U.S. person for U.S. federal income tax purposes, and the Proposed Owner
is not acting on behalf of a U.S. person. A U.S. person is either a resident or a citizen of the U.S. or an entity organized in the U.S. A fatse statement or misrepresentation by

a U.S. person could lead to penalties under U.S. law. If your tax status changes and you become a U.S. citizen or resident, you will notify us within 30 days.

APA 408G-0611

7o0f8

1)

D

UC
eclaration of Beneficial Owne:

I, the Proposed Owner, hereby declare and confirm that, untess otherwise indicated below’, | am the Beneficial Qwner and ultimately own or have effective control over
this insurance policy. | acknowledge and agree that the Company shail be entitled to rely on my declaration above on the beneficial ownership and purpose of this
insurance policy.

(To be completed only if you are not the Beneficial Owner)
*The following individual(s) is/are the Beneficial Owner(s} and ultimately own(s) or has/have effective control of this insurance policy. Please enclose a copy of the
identity card or passport of the Beneficial Owner(s}.

NRIC/Passport Date of Relationship to the
Name(s) NRIC Type Number Nationality Birth policyholder

‘Beneficial Owner’ as defined in MAS Notice 314 on Prevention of Money Laundering and Countering the Financing of Terrorism means the natural person who ultimately
owns or controls a customer or the person on whose behalf a transaction is being conducted and includes the person who exercises ultimate effective control over a
body corporate of unincorporate.

For the avoidance of doubt, ‘Beneficial Owner’ dees nat mean the nominated beneficiarylies) under the policy.

Authorized Signatures

Signed at on
City, Country Date (mm/dd/yyyy}
x x
Signature of Proposed Insured {or parent or guardian if Proposed insured is a minor Witness to Signature of Proposed Insured
Signed at on
City, Country Date {(mm/dd/yyyy)
x x
Signature of Proposed Owner (if other than Proposed Insured) Witness to Signature of Proposed Owner

If Proposed Owner is a corporation, an authorized officer, other than the Proposed Insured must sign as a Proposed Owner, give full corporate title and name of corporation
with the company stamp below. If Proposed Owner is a Trust, authorized Trustee(s} must sign as Proposed Owner, give full name and date of Trust below.

[x

Signature of Insurance Advisor

INO AA

APA 4056-0611 8of8
(NOT PART OF APPLICATION)

Report by Distributor

Distributor's Name Office 1D Producer ID (Distributor)

Solicitors Name Producer ID (Solicitor) Producer MAS Representative Notificatian Framework ID

Administrative Statf Name

Solicitor's Statement

1. What is the purpose for insurance?

2. How long have you known the Proposed Insured?

3. Proposed Insured is

Single | Married Divorced Widowed

. To the best of your knowledge, does the Proposed Insured have any existing life insurance or Yes
annuity policies?

. To the best of your knowledge. could replacement be involved? Yes

. Name of referring bank.

. ts this Application submitted in respect of an Accredited Investor as defined in the Financial Advisers Act (Chapter 110)? Yes
HE 'No’. please attach a copy of the option page of the Fact Find Form with this Statement.

Solicitor’s Declaration

| have personally seen the Proposed [nsured/Owner and explained the terms of the insurance to him/her and have verified the NRIC/Passport No. of the
Proposed Insured/Owner.

{ declare that all the answers provided to me by the Proposed Insured/Qwner are accurately declared in the Application. | have not withheld any other information which
may influence the acceptance of this Application by the Company.

Date (mm/dd/yyyy) Signature of Solicitor

APA 40SG-0611