Date: Client: Advisor

INTERMEDIARY DISCLOSURE DOCUMENT AND SECTION 13 CERTIFICATE ABOUT THE BROKERAGE ABOUT THE REPRESENTATIVE FSP Name : Full Name : FSP No. : E-mail : Physical Address : Cell No. : Postal Address : Status : Fully Accredited / Under Supervision Telephone : This FSP certifies that the above representative is mandated in terms of an employment contract, to render financial services Fax : (advice and intermediary services) relating only to the products Company Registration No. : as indicated on this document. This FSP accepts responsibility for the activities of the representative performed within the Medical Accreditation No. : ORG course and scope of such representative’s employment. Receive more than 30% of last year’s The FSP and the representative confirm that he/she is Fit and commission and remuneration from a particular Y N Proper to render financial services. insurer (if yes, state name of insurer) Key Individual Signature: Directly or indirectly hold more than 10% of an Y N Medical Accreditation No. : BR insurer’s shares Holds PI cover Y N Qualification : Third Party Collection Agency (if yes, state the Experience : Y N name) Regulatory Exams : Is an associated company of an insurer Y N : Honesty & Integrity Date A copy of the FSP licence as well as any exemptions is Assessment: Outcome : available on request. BROKERAGE PRODUCT REGISTRATION REPRESENTATIVE PRODUCT REGISTRATION Long Term A, Long Term B1, Short Term Personal Lines, Long Term A, Long Term B1, Health Benefits Retail Pension Benefits, Health Benefits PRODUCT SUPPLIERS THAT HAVE GIVEN THE PRODUCT SUPPLIERS THAT THE REPRESENTATIVE BROKERAGE WRITTEN AUTHORITY TO MARKET IS ACCREDITED TO MARKET THEIR PRODUCTS Old Mutual, Sanlam, Liberty, Discovery, Zurich Old Mutual, Discovery

REMUNERATION I receive commission and charge fees as follows: COMPLIANCE OFFICER FAIS Compliance and Licensing CC, Tel: 0832573129, Address: 51 Wilkes Road, Sheffield Beach, 4420 FAIS OMBUD Address: Sussex Office Park Ground Floor, Block B, 473 Lynnwood Road Cnr Lynnwood Road & Sussex Ave, Lynnwood, 0081 Tel: (012) 4709080 ; Fax: (012) 3483447 CONFLICT OF INTEREST I may from time to time receive non-cash incentives from product suppliers or indirect consideration from other persons. I will provide specific details, including my Conflict of Interest Policy, should you request further information. We endeavour not to pursue transactions where there is a conflict of interest. CONFIDENTIALITY All information obtained or acquired about you shall remain confidential unless you provide written consent, or unless I am required by any law to disclose such information. COMPLAINTS In the event that you are dissatisfied with any aspect of my service, you should address your complaint in writing to the brokerage. A copy of our Complaints Resolution Policy is available on request. Please note that before you lodge a complaint with the FAIS Ombud, you have to first try to resolve the complaint with our office. PROTECTION OF PERSONAL INFORMATION ACT 4 OF 2013 The Protection of Personal Information (POPI) Act requires us to obtain your consent and inform you on how we use and disclose your personal information. The Consent and Notice form will be provided to you for signature. We are committed to protecting your privacy and will ensure that your personal information is used appropriately, transparently and according to applicable law. A copy of our Protection of Personal Information Manual is available on request. TREATING CUSTOMERS FAIRLY (TCF) We are required to demonstrate that we are consistently delivering fair outcomes to our customers. Senior management is responsible for ensuring that the brokerage and staff at all levels, deliver customer outcomes relevant to the business through establishing an appropriate culture of fairness. We recognise the fair treatment of our customers and undertake to provide excellent customer service based on accountability and transparency. A copy of our TCF Commitment Statement is available on request.

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