: "TRANSAMERICA Transamerica Life (Bermuda) Ltd. Overseas

LIFE BERMUDA LTD Singapore Branch Office

1 Finlayson Green Resident’s
#13-00 . .
Singapore 049246 Questionnaire

Co, Reg. No. TOSFC6768E

Policy Number Proposed Insured

(please print)

What is the purpose of this Questionnaire?

This Questionnaire is required with all applications on individuals who are residents of a city/country other than Singapore. Transamerica
Life (Bermuda) Ltd., (“Transamerica”) does not permit company and/or Transamerica product-specific discussions or presentations or any
activities associated with solicitation in jurisdictions outside of Singapore.

Who needs to complete the Questionnaire?

The Producer and the Applicant must complete and submit this Questionnaire on individuals that are residents of a city/country other than
Singapore. Please answer each question in as much detail as possible. For purposes of this Questionnaire, the term “Appficant" refers to: (a)
the proposed owner of the policy if the owner is a natural person; or (b) the proposed insured if the proposed owner is not a natural person.

1. Please provide the date and city/country where the Producer first engaged in Transamerica product-specific discussions or provided
Transamerica identified marketing, sales materials or illustrations to the Applicant.

Date: __ City/County:
2. Have all of the solicitation activities regarding the Transamerica product taken place in Singapore?
' Yes |! No

If no, please give the details:
3. Please indicate the city/country where the Transamerica insurance documents were completed and signed.
\_ Singapore ! Other:

Please submit documentation demonstrating the place where the Applicant was at the time the Transamerica insurance documents
were completed and signed (such as a valid entry permit, visa, passport stamp, or other government-provided evidence).

4. Did anyone other than the Producer assist in completing the Transamerica insurance documents or provide any Transamerica-specific
product information:

™ Yes i! No

If yes, please give the details:

5. Additional Information:

SPECIAL INFORMATION: For Application involving a Proposed Insured residing in the People’s Republic of China (PRC),
please read and confirm the following statements are accurate. Do not sign this Form unless all of the representations con-
tained below are true.

1. While in the PRC, | have had no discussions with the Producer regarding either life insurance or Transamerica.

2. |lreceived no documentation, including marketing materials, illustrations or applications regarding life insurance or Transamerica while
in the PRC.

3. My travel to Singapore in connection with my application for a Transamerica policy was not arranged or organized by any Producer.
4. Application and all insurance-related documents associated with the application for life insurance on my life were signed in Singapore.

IMPORTANT NOTICE: The laws related to life insurance products, including tax and estate laws, vary by country. Transamerica does
not provide tax or legal advice and Applicants are encouraged to consult with their own tax and/or legal counsel regarding the purchase
of life insurance products.

| certify that the above information is accurate:

Applicant Name (please print) Applicant Signature Date

Producer Name With Producer Code Producer Signature Date
{please print)
TOA 445SG-0612