Transamerica Life (Bermuda) Ltd. Personal Supplement
J Ti Singapore Branch Office . .
RANSAMERICA I Finlayson Green to Application for
. LIFE BERMUDA LTD #13-00 Life Insurance
Singapore 049246
Co. Reg. No. TOSFC6768E

Policy No.:

Name of Proposed Insured: Date of Birth:

Please fill in all the figures in US Dollars
Section A PURPOSE OF INSURANCE

1. 1 Personal 2. i Business
LI Income Replacement _ Keyperson
LI Estate Planning _ Stock Repurchase
i Protection for Dependents ~ Buy-Sell

~ Requested by Creditor to Secure Loan
Amount of Loan Secured $
Is Insurance required by the Creditor? Yes 11 No

3. How was the amount of insurance applied for determined?

4. Employment Information Proposed Insured

Occupation

Commencement Date of Employment

Main Duties

No. of Employees in the Company

Percentage of Company Shares Owned,
if any

5. Number of Dependents & Relationship to the Proposed Insured

6. Residential Property
“| Selfowned [1 Fully Paid "1 Mortgaged |. MortgageAmount $

| Rented Monthly Rental $

NO

APE 56SG-0109 *DT145 *

Policy No.:
Name of Proposed Insured:

If you are applying for personal insurance, please proceed to question 10-13.

Section B BUSINESS INFORMATION

7. |] Yes .. No Ifthe purpose of this insurance is related to business, are other Corporate Officers
or Partners in the business also being insured?

Please give details and explanation.

8. Percent of corporation or partnership owned by Proposed Insured?
9. Corporation’s or Partnership's

Estimated Current Year Past Year

Net Worth $

Gross Sales $

NetIncome $

10. Please fill in figures in thousand dollars (000)

Estimated Year Estimated
Current | Last Year |porore Last Current | Last Year
Year Year

ANNUAL INCOME ASSETS
Earned Income Cash

Annual Salary or

Wages Real Estate*

Bonuses : Stocks & Bonds

Other Earned Income Autos

Total Earned Income Personal

Business Equity

Unearned Income Other

Dividends & Interest Total Assets

Net Real Estate Income

Net Business Investment LIABILITIES
Income

Other Mortgages

Total Unearned Income Personal Loans

Business Loans

All Other
Personal
Liabilities
TOTAL ANNUAL TOTAL
INCOME LIABILITIES

APE 56SG-0109
Policy No.:
Name of Proposed Insured:

* Real Estate Details

Current
Value

Date of Purchase

Purchase Price Mortgage

Address of Properties

11, Estimated Net Worth of Proposed Insured $

12. !!Yes | No At this time do you have an undischarged bankruptcy? If yes, give type and details.

13. '! Yes |! No Do you have a prepared financial statement? If yes, please attach a copy.

It is represented that the statements and answers given in this Supplement to the Application are true, complete and
correctly recorded to the best of my knowledge and belief. It is agreed that this Supplement shall be a part of the
Application to Transamerica Life (Bermuda) Ltd. for insurance on the life of the Proposed Insured, and shall be the
basis for any policy issued on the Application.

Signed at

City, Country Date (mmidd/yyyy)

Signature of Proposed Insured Witness to Signature of Proposed Insured

Print Full Name Print Full Name

AGREEMENT OF PROPOSED OWNER IF OTHER THAN PROPOSED INSURED

The Proposed Owner agrees to be bound by all statements, answers, and agreements made by the Proposed Insured
in this Supplement to the Application. If Proposed Owner is a corporation, an authorized officer, other than the Proposed
Insured must sign as Proposed Owner. In such an event, please provide the full Corporate title, full name of the officer
signing, and the full name of Corporation with the company stamp in the space below.

Signed at

City, Country Date (mm/dd/yyyy)

Signature of Proposed Owner Witness to Signature of Proposed Owner

Print Full Name Print Full Name

Corporate Title
Officer's Name
Corporation Name

APE 56SG-0109