MAX INVESTMENTS

Licensed Financial Services Provider

EXTENDED INVESTMENT FUNDS FORM

(Replaces Section 5 of the Application form)

(OM44/1)

INVESTMENT ALLOCATIONS (Please ensure that the funds selected on this page total 100% per plan)

INTERNAL Investment Funds

Life: Pure Investment & Retirement Annuity
Committed Investment (Premium %) Select Select Investment Investment (Once-off %) (Scheduled %)

INTERNAL Investment Funds

LISP: Pure Investment Life: Pure Investment & Retirement Annuity
Committed Investment (Premium %) Select Select Investment Investment (Once-off %) (Scheduled %)

Market Growth Fund Category Optimised High Growth Optimised Growth Optimised Balanced Optimised Aggressive Multi-manager Growth Multi-manager Balanced SA Bonds SA Quoted Property Symmetry Islamic Fund Optimised World Active Optimised World Balanced Optimised World Defensive Optimised World High Growth Multi-manager World Balanced Multi-manager World Defensive Multi-manager World High Growth Euro Money Market Sterling Money Market US Dollar Money Market World Bonds World Equity Asia Pacific Continental Europe Japan UK USA SA Consumer & Industrial Sector SA Financial Sector SA Mining and Resources Sector SA Small Companies Womens Activism Balanced Fund Defence Fund Category SA Money Market Optimised Defensive Multi-manager Defensive Wealth Defender1 Guarantee Fund Category Secured Money Market Smoothed Performance Growth Preserver Optimised Balanced with Guarantee
4

Market Growth Fund Category *Old Mutual Top Companies *Old Mutual Investors *SYmmETRY Equity FoFs 2 *Old Mutual Balanced *Old Mutual Flexible Fund *Old Mutual Gilt *Old Mutual High Yield Opportunity *Old Mutual SA Quoted Property *Old Mutual Umbono Top 40 Old Mutual Umbono RAFI 40 Tracker Fund *Old Mutual UK Money Mkt Feeder * *Old Mutual Global Bond Feeder
*Old Mutual International Growth FoF s

*Old Mutual Global Equity A Class *Old Mutual Financial Services *Old Mutual Gold *Old Mutual Small Companies *Old Mutual Industrial *Old Mutual Growth *Old Mutual Income *Old Mutual Mining & Resource *Old Mutual Value Defence Fund Category *Old Mutual Money Market 3 *Old Mutual Enhanced Income Old Mutual Stable Growth Fund - A Class *Old Mutual Real Income *Old Mutual Dynamic Floor *SYmmETRY Money Market 2,3 *SYmmETRY Fixed Interest FoFs 2 *SYmmETRY Defensive FoFs 2 *SYmmETRY Balanced FoFs
* Unit Trust Funds
1 2
2

See Clause C16 - Declarations Management Company for the Galaxy Multi-manager Unit Trust Funds: Old Mutual Unit Trust Fund Managers Ltd, P.O. Box 207, Cape Town 8000 3 Available under LISP Pure Investment only. 4 Available under the Life Retirement Annuity only.

OTHER Investment Funds

LISP: Pure Investment Life: Pure Investment & Retirement Annuity
Committed Investment (Premium %) Select Select Investment Investment (Once-off %) (Scheduled %)

LISP: Pure Investment Life: Pure Investment & Retirement Annuity

Committed Investment (Premium %)

Select Select Investment Investment (Once-off %) (Scheduled %)

Proposal Number:

Check Digit:

Existing Contract Number:

OCTOBER 2008

Greenroom Stock No. APP0032 JB14547

MAX INVESTMENTS
Licensed Financial Services Provider

(Replaces Section 5 of the Application form) INVESTMENT ALLOCATIONS (Please ensure that the funds selected on this page total 100% per plan)

EXTENDED INVESTMENT FUNDS FORM

EXTERNAL Investment Funds (Unit Trust Funds)

LISP: Pure Investment Life: Pure Investment & Retirement Annuity
ABSA Balanced ABSA Dividend Income ABSA Flexible ABSA General ABSA Growth FoFs ABSA International FoFs ABSA Select Equity Allan Gray Balanced Allan Gray Equity Allan Gray Orbis Global FoFs Allan Gray Optimal Allan Gray Stable Cadiz Absolute Yield Fund Cadiz Balanced Fund Cadiz Mastermind Fund Coronation Absolute Coronation Balanced Defensive Fund A Class Coronation Balanced Plus Coronation Bond Coronation Capital Plus Coronation Dynamic Protector Fund A Class Coronation Equity - A Class Coronation Financial Coronation Industrial Coronation Market Plus Coronation Optimum Growth Coronation Property Equity Coronation Resources Coronation SA Capital Plus Coronation Strategic Income Coronation Top 20 Efficient Flexible FoFs Efficient Prudential Fund Futuregrowth Albaraka Equity Investec Absolute Balanced Investec Absolute Income Investec Cash Plus - B Class Investec Commodity - B Class Investec Emerging Cos - B Class Investec Equity - B Class Investec Gilt - B Class Investec Global Opp. Inc. FoFs - B Class Investec High Income - B Class Investec Managed - B Class Investec Opportunity - B Class Investec Opportunity Income Investec Value - B Class Investec World Wide Equity Feeder Marriott Core Income Marriott Dividend Growth Marriott Global Income Growth Feeder Fund Marriott Global Real Estate Marriott Income Marriott Property Equity Marriott Property Income
Committed Select Select Investment Investment Investment (Premium %) (Once-off %) (Scheduled %)

EXTERNAL Investment Funds (Unit Trust Funds)

LISP: Pure Investment Life: Pure Investment & Retirement Annuity
Nedgroup Investments Equity Fund - A Class Nedgroup Investments Flexible Income Nedgroup Investments Growth Fund Nedgroup Investments Inflation Beater - A Class Nedgroup Investments Managed - A Class Nedgroup Investments Positive Return Fund - A Class Nedgroup Investments Rainmaker - A Class Nedgroup Investments Stable Fund Nedgroup Investments Value - A Class Oasis Crescent Equity Fund Prudential Dividend Maximiser Prudential Global High Yield Bond FoFs Prudential Global Value FoFs Prudential High Yield Bond Prudential Inflation Plus Prudential Equity Fund Prudential Balanced Fund PSG Advance Wealth Creator FoFs PSG Advance Wealth Income FoFs PSG Advance Wealth Moderate FoFs PSG Advance Wealth Preserver FoFs PSG Alphen Equity FoFs - Class C PSG Alphen Income FoFs - Class C PSG Alphen Prudential FoFs RMB Absolute Focus RMB Balanced - A Class RMB Bond RMB Conservative Fund RMB Emerging Companies RMB Equity - A Class RMB Financial Services RMB High Tide Fund RMB High Dividend Fund RMB Income Plus Fund RMB International Equity FoFs RMB Moderate Fund RMB Maximum Income RMB Strategic Opportunities - A Class RMB Top 40 Index RMB Value RWM Balanced FoFs - Class B1 RWM Cautious FoFs - Class B1 Sanlam Balanced Sanlam Financial Sanlam General Equity - A Class SIM Inflation Plus Sentinel Diversified Income FoFs Sentinel Flexible FoFs Sentinel Prudential FoFs STANLIB Euro Currency FoFs - A Class STANLIB Income - R Class STANLIB Property Income - A Class STANLIB Stability - R Class STANLIB US Dollar Cash FoFs - A Class Sygnia Alpha Plus Fund
Committed Select Select Investment Investment Investment (Premium %) (Once-off %) (Scheduled %)

OTHER Investment Funds

LISP: Pure Investment Life: Pure Investment & Retirement Annuity
Committed Investment (Premium %) Select Select Investment Investment (Once-off %) (Scheduled %)

LISP: Pure Investment Life: Pure Investment & Retirement Annuity

Committed Investment (Premium %)

Select Select Investment Investment (Once-off %) (Scheduled %)

(OM44/2) Proposal Number:

Check Digit:

Existing Contract Number:

OCTOBER 2008

Greenroom Stock No. APP0032 JB14547