2. Investment Application : Portfolio Bond-Single Premium Saving Plan – My Wealth Capital

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2.1 Investment Application : Portfolio Bond - Single Premium Saving Plan

Step 1 of 15

6%

International Wealth : All references to International Wealth Mean International Wealth as a cell of International Assurance Limited PCC and;
IAL: All references to IAL Mean International Assurance Limited PCC

SECTION 1 : APPLICANT DETAILS #1
First Applicant
Title*
- Mr
- Mrs
- Miss
- Ms
- Dr
- Other
Date of Birth*
MM slash DD slash YYYY
First Name*
First name (s)
Surname*
Surname
Please note that at least one life assured is required.
Do you wish to be the life assured?*
- Yes
- No
Physical address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Country and place of birth*
Country of residence*
Country
Nationality*
Country
Email address*
Taxation country of residence*
Tax reference no
Passport / ID Number*
Expiry date
MM slash DD slash YYYY
Tel (home)
Tel (mob)
Tel (office)
Facsimile
Verification of identity, that is, a certified true copy of the current passport for EACH individual Applicant carrying a photograph of the individual and proof of address must be submitted with this Application Form. Evidence of current address must be no older than 3 months and show physical place of residence.
Do you wish to submit a Second Applicant?
Second Applicant*
- Yes
- No
First Applicant Online Signature*
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat

ThisIsMe Verification
Please follow the link and get verified to continue filling in this application.
ThisIsMe Verification
Has verification been done?*
- Verified
First Name*
First name (s)
Surname*
Surname
First Applicant Online Signature*
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat

SECTION 1 : APPLICANT DETAILS #2
Second Applicant
Title*
- Mr
- Mrs
- Miss
- Ms
- Dr
- Other
Date of Birth*
MM slash DD slash YYYY
Name*
First Name (s)
Surname*
Surname
Please note that at least one life assured is required.
Do you wish to be life assured?*
- Yes
- No
Physical address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Country and place of birth*
Country of residence*
Country
Nationality*
Country
Email address
Taxation country of residence*
Tax reference no
Passport/ ID number*
Expiry date
MM slash DD slash YYYY
Tel (home)
Tel (mob)
Tel (office)
Facsimile
Verification of identity, that is, a certified true copy of the current passport for EACH individual Applicant carrying a photograph of the individual and proof of address must be submitted with this Application Form. Evidence of current address must be no older than 3 months and show physical place of residence.

LIFE ASSURED
If you are only insuring the lives of the Applicant/s, and you have ticked the relevant boxes above, please DO NOT complete this subsection. There must be at least one life assured.
Title
- Mr
- Mrs
- Miss
- Ms
- Dr
- Other
Date of Birth
MM slash DD slash YYYY
Name
First Name (s)
Surname
Surname
Do you wish to be the life assured?
- Yes
- No
There must be at least one life assured.
Physical address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
First Applicant Online Signature
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY

SECTION 2 : BENEFICIARY DETAILS
First Beneficiary
Title*
- Mr
- Mrs
- Miss
- Ms
- Dr
- Other
Name*
First Name (s)
Surname*
Surname
Date of Birth*
MM slash DD slash YYYY
Country of residence*
Country
Nationality*
Country
Passport/ID Number*
Add a second beneficiary?*
- Yes
- No
SECOND BENEFICIARY
Title
- Mr
- Mrs
- Miss
- Ms
- Dr
- Other
Name
First Name (s)
Name
Surname
Date of Birth
MM slash DD slash YYYY
Country of residence
Country
Nationality
Country
Passport Number
Add a third beneficiary?*
- Yes
- No
Third Beneficiary
Title
- Mr
- Mrs
- Miss
- Ms
- Dr
- Other
Name
First Name (s)
Name
Surname
Date of Birth
MM slash DD slash YYYY
Country of Residence
Nationality
Passport/ID Number
Verification of identity, that is, a certified true copy of the current passport for EACH individual Applicant carrying a photograph of the individual and proof of address must be submitted with this Application Form. Evidence of current address must be no older than 3 months and show physical place of residence.
First Applicant Online Signature*
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
Date*
DD slash MM slash YYYY

SECTION 3 : INVESTMENT DETAILS
Investment Details
Basis of Contract
Plan Reporting Currency*
- USD
- EUR
- GBP
- ZAR
Total Currency Amount Invested*
Select Currency*
- USD
- EUR
- GBP
and/or
Total Coin Number Invested
Select Crypto
- BTC
Source of Funds - Applicant 1
Occupation Details & Income - Applicant 1
Estimated Income in USD p.a. (applicant)
Estimated Income in USD p.a. (spouse)
Occupation
Applicant's Business name and Address
Size (staff, turnover, etc)
Applicant(s) visited?*
- Yes
- No
If yes, where?
- Home
- Business Premises
If yes, by who? Frequency?
Gifts & Inheritance - Applicant 1
Name of Benefactor
First Name (s) Surname
Name of Beneficiary
First Last
Relationship between benefactor, beneficiary and applicant
Amount Received in USD
Date Received
MM slash DD slash YYYY
Disposal of a Business or a Significant Asset - Applicant 1
Details (business/significant asset)
Name of Owner
Relationship between the owner of business/asset and applicant
Amount Received in USD
Date Received
DD slash MM slash YYYY
Approximate net Worth*
- Up to 1mil USD
- Up to 2mil USD
- Up to 5mil USD
- Up to 10mil USD
- Other
Other information
Any public position currently or previously held? (if Yes, please provide details below)
- Yes
- No
Other information
Financial Advisor Declaration - APPLICANT 1
This information originates from my first-hand knowledge of the client's circumstances (if this is not the case, the reasons are)
Financial Advisor's Signature
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
First Applicant Online Signature*
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date*
DD slash MM slash YYYY
Please provide supporting evidence where necessary.

Source of Funds - Applicant 2
Ocupation Details & Income - Applicant 2
Estimated Income in USD p.a. (applicant)
Estimated Income in USD p.a. (spouse)
Occupation
Applicant's Business name and Address
Size (staff, turnover, etc)
Applicants visited?
- Yes
- No
If yes, where?
- Home
- Business Premises
If yes, by who? Frequency?
Gifts & Inheritance - Applicant 2
Name of Benefactor
First Name (s) Surname
Name of Beneficiary
First Name (s) Surname
Relationship between benefactor beneficiary and applicant
Amount Received in USD
Date Received
MM slash DD slash YYYY
Disposal of a Business or a Significant Asset - Applicant 2
Details (business/significant asset)
Name of Owner
Relationship between the owner of business/asset and applicant
Amount Received in USD
Date Received:
MM slash DD slash YYYY
Approximate net Worth
- Up to 1mil USD
- Up to 2mil USD
- Up to 5mil USD
- Up to 10mil USD
- Other
Other information
Any public position currently or previously held? (if Yes, please provide details below)
- Yes
- No
Other information
Financial Advisor Declaration - Applicant 2
This information originates from my first-hand knowledge of the client's circumstances (if this is not the case, the reasons are)
Financial Advisor's Signature
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
Second Applicant's Signature
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Please provide supporting evidence where necessary.

Investment Instructions

FUND NAME	ISIN or SEDOL	CURRENCY
MY WEALTH CAPITAL AGGRESSIVE SUB-FUND	xxx	USD/BTC
MY WEALTH CAPITAL BALANCED SUB-FUND	xxx	USD/BTC
MY WEALTH CAPITAL INCOME SUB-FUND	xxx	USD/BTC

Please enter the percentage to be invested per Fund below:
MY WEALTH CAPITAL AGGRESSIVE SUB-FUND*
Please enter a number from 0 to 95.
My Wealth Capital Aggressive Sub-Fund Fact Sheet
MY WEALTH CAPITAL BALANCED SUB-FUND*
Please enter a number from 0 to 95.
My Wealth Capital Balanced Sub-Fund Fact Sheet
MY WEALTH CAPITAL INCOME SUB-FUND*
Please enter a number from 0 to 95.
My Wealth Capital Income Sub-Fund Fact Sheet
Please enter the percentage to be invested per sub-fund above to a total of 95% for your asset allocation. At all times the minimum of 5% must be held in Cash. Initially, all cash or fiat currency investments will be held in Cash until allocation by the Financial Advisor.
CASH (Cash values may be between minimum 5% - 100%.)*
Please enter a number from 5 to 100.

SECTION 4 : INVESTMENT MANAGEMENT
APPOINTMENT OF FINANCIAL ADVISOR
I/We appoint the Financial Advisor to act in the capacity of an advisor to my/our policy.
1. I/ We understand that the Financial Advisor will act on my/our behalf in accordance with the terms and conditions specified in sections below, to advise on and change the investment portfolios to which the value of my/our policy is linked. I authorise International Wealth to provide all relevant information relating to my/our policy to my/our Financial Advisor when requested.
2. I/We agree that International Wealth shall not be responsible for any loss or liability incurred to my/our policy as a result of the actions, or failure to take actions, by my/our appointed Financial Advisor.
3. I/we agree to indemnify International Wealth, the Company, its officers, all shareholders in and the directors of the Company and cells and holds them harmless against any claims that might hereafter be made against them arising from this arrangement.
4. I/ We confirm that all communications in relation to investment instructions should be directed to my/our Financial Advisor.
5. I/We confirm that I/We will inform International Wealth in writing immediately, should I/We decide to change my/our Financial Advisor or bring this agreement to end in the future.
6. I/We acknowledge that International Wealth has the right to reject the appointment of my/our Financial Advisor at its discretion and that International Wealth is entitled, at its absolute discretion, to refuse or accept an investment instruction properly given by the Financial Advisor.
Discretionary authority:
I/We confirm that the Financial Advisor will be acting on a discretionary basis. This means the Financial Advisor has complete discretionary authority, without consulting me/us, to make investment decisions, to buy or sell securities, hold cash or other investments. I/We authorise International Wealth to act upon the investment instructions of the Financial Advisor. Investment instructions may be forwarded to International Wealth without my/our prior consultation. *
PLEASE TICK BELOW:*
- I have read and understand the discretionary authority above
FINANCIAL ADVISOR DETAILS AND CONDITIONS

(This section should be completed by the Financial Advisor)

Financial Advisor Name :	My Wealth Capital Private Equity Holding (Propriety) Limited
Financial Advisor Firm's Name :	My Wealth Capital Private Equity Holding (Propriety) Limited
Financial Advisor Address :	10 Kerby Street, Windhoek, Namibia
Financial Advisor Telephone :	+264 81 420 0231
Financial Advisor Email :	admin@firstnamibia.co.za

DECLARATION BY FINANCIAL ADVISOR

In our/my capacity of Financial Advisor to this policy, I/we agree to the following terms and conditions:
1. All instructions should be received in a format as agreed by International Wealth.
2. International Wealth reserves the right to accept/reject any instruction from the Financial Advisor.
3. The Financial Advisor agrees to provide copies of discussions with the Policyholder, for evidence, where the Financial Advisor is acting on a non-discretionary basis. The Financial Advisor has the duty to maintain these records.
4. The Financial Advisor confirms that it has such authorisations and licences with such regulatory bodies as is necessary to act as appointed Financial Advisor and agrees to notify International Wealth in writing, immediately should this authorisation change or cease.
5. International Wealth reserves the right to remove the Financial Advisor from the Policy without specifying a reason and on giving one-month written notice to the Policyholder and the Financial Advisor.
6. The Financial Advisor may resign his appointment by giving one month’s written notice to the Policyholder and International Wealth.
7. The Financial Advisor appointment shall cease immediately upon the death, bankruptcy, dissolution, conviction for criminal offence or insolvency of the Financial Advisor or if the Financial Advisor is in breach of any regulatory requirement or it becomes illegal for the Financial Advisor to act in this capacity.
8. The Financial Advisor confirms that they have independently verified all the relevant applicants’ identities and personal details, as disclosed in this Application Form, and enclose certified copies of all requisite documents for International Wealth’s records.
9. Financial Advisor confirms that they are not aware of any reason why this application and investment should not be concluded.
10. The Financial Advisor confirms that they have taken reasonable steps to ensure that the Applicant(s) funding is legitimate to the best of their knowledge; all the information provided by the Applicant(s) is true and complete and has been obtained by them, from the Applicant(s).
11. The Financial Advisor declares that, to the best of their knowledge and belief, the information given in this Application Form is true and complete.
12. The Financial Advisor declares that they have not made any changes to the Application form after the authorised signatories/Applicant have signed it.
13. The Financial Advisor declares that they have informed the Applicant(s) of International Wealth’s Data Protection and Privacy Policy and explained to the Applicant(s) their rights as Data Subjects in relation to the Data Protection Act 2017.
14. The Financial Advisor declares that they have provided to the Applicant(s) all necessary product information, including all fees, charges and commissions, in connection with this Portfolio Bond - Single Premium Plan and the underlying investment instruments that the Financial Advisor has proposed to the Applicant(s).
Financial Advisor's Signature
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
First Applicant Online Signature*
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date*
DD slash MM slash YYYY

SECTION 5 : CHARGES SCHEDULE
Establishment Charges
INTERNATIONAL WEALTH ESTABLISHMENT CHARGE 0.25% only if the Financial Advisor's fee is > than 0%
Please take note of the following charging structures:

Advisor Initial Fee 7.5% International Wealth Initial Administration Fee 0.25% Total Initial Charges 7.75%
PLEASE TICK BELOW:*
- I have read and understand the charges schedule above
Ongoing Fees
QUARTERLY POLICY FEE USD 25
INTERNATIONAL WEALTH

QUARTERLY ADMINISTRATION FEE	As per the table below:
Less than 50,000	0.65% p.a.
50, 001 to 100,000	0.55% p.a.
100,001 to 250, 000	0.45% p.a.
Greater than 250, 001	0.35% p.a.

QUARTERLY FINANCIAL ADVISORY FEE 2% p.a
Financial Advisor's Signature
First Applicant Online Signature*
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date*
DD slash MM slash YYYY

SECTION 6 : APPLICANT/S DECLARATION
Please carefully read through the following declaration before accepting.

Download Terms and Conditions

1.I/We warrant in favour of International Wealth that:

1.1 I/We confirm that I/We have read the product literature including the policy Terms and Conditions.

1.2 I/We hereby consent to receiving our Policy Schedule and Terms and Conditions in digital format (should the Applicant(s) wish to receive their Policy Schedule and Terms and Conditions in paper-based form, then the Applicant(s) should notify International Wealth of their requirement).

1.3 By signing this Application, I/We agree to the policy being governed by the policy Terms & Conditions. I/We confirm that all of the information I/We have provided in this application, along with any supporting forms, questionnaires, statements, reports or other information are true and complete.

1.4 I/We confirm that to the best of our knowledge and belief, I/We are not subject to any legislation that would make my/our investment into this policy unlawful.
1.5 I/We are aware that International Wealth does not provide investment advice, is not responsible for managing the investments and does not determine whether or not investments are suitable for me/us. I/We understand that International Wealth offers access to a range of investment instruments including funds, shares, ETF’s and structured notes offered by external companies. I/We accept that ultimate responsibility for the selection of investments lies with me/us and/or our appointed Financial Advisor; if funds underperform and as a consequence the policy drops in value, I/We accept this is not the fault of International Wealth.

1.6 I/We request that International Wealth allocates my/our premium to the investments selected as part of this Application. In order for International Wealth to do this I/We confirm the following:
a) I/We agree to International Wealth acting on instructions received from me/us or our appointed Financial Advisor, and I/We will read the documentation issued by the fund manager/product promoter for each investment prior to selecting it for our policy.
b) I/We are aware that some investments may have terms and conditions that could: restrict International Wealth from realising a cash value when requested and prevent International Assurance paying out benefits from the policy in a timely fashion; result in International Wealth having to pay back some or all of the sale proceeds if an adjustment has to be made after the payment. If International Wealth is required to make such a repayment and the policy value is too low to cover it, or I/we have surrendered the policy, I/We agree to compensate International Wealth for any loss that it has suffered as a result.
c) I/We accept that International Wealth has the right to sell funds linked to the policy without requiring our permission. International Wealth may do this if it decides that a fund may have harmful legal, tax or other consequences under law.
d) I/We are aware that there may be fees to pay when International Wealth sells one or more of the investments linked to the policy. Any fees due when selling an investment should be detailed by the fund manager/product promoter in the fund/product documentation.
e) I/We confirm that I/We are aware of the fees that I/We may pay in relation to our chosen investments.

1.7 I/We have fully familiarised ourselves with any applicable income tax and exchange control laws and regulations regarding the purchase of investments.

1.8 I/We are not prevented or restrained legally, commercially or otherwise from purchasing the product from International Wealth in accordance with the terms of this agreement.

2. I/We hereby indemnify International Wealth, the Company, its officers, all shareholders in and the directors of the Company and cells and hold them harmless against any claims that might hereafter be made against them arising from the purchase or sale of any investments.

3. I/We declare that I/we are not, nor are any beneficiaries nor lives assured, resident in Mauritius for the purpose of the Income Tax Laws in force in Mauritius and undertake to notify International Wealth if this declaration ceases to be correct.

4. I/We understand our application will not be accepted unless cleared funds and the applicable Know Your Client information has been received with valid supporting documentation. Details of the required additional documentation are available on request from your Financial Advisor. The Compliance Officer reserves the right to request any further documentation as and when required.

5. I/We the undersigned, confirm that I/We have read this application and accept the terms and conditions, which may be amended from time to time. The Terms & Conditions are also available on the company's website - www.international-assurance.com

6. I/We acknowledge and agree that:

6.1 International Wealth has informed us that it has a Data Protection and Privacy Policy which is available on its website as a download;

6.2 International Wealth has informed us that it has a Complaints Handling Policy which is available on its website as a download;

6.3 information provided to International Wealth by me/us will be stored on their computer systems and manually by its agents and delegates;

6.4 I/We as the Guardian/parent of the Child ( Minors under the age of 16 years of age ) under the beneficiaries section of this application form hereby consent to the use of the Data provided;

6.5 for the purposes of the Data Protection Act 2017 in force in Mauritius (the “Data Protection Law”) and other relevant data protection legislation which may be applicable, International Wealth is required to specify the purposes for which it will hold personal data. International Wealth will only use such information for the purposes set out below (collectively, the “Purposes”), being to:

6.5.1 process our personal data (including sensitive personal data) as required by or in connection with our investments with International Wealth including the processing of personal data in connection with credit and money laundering checks on ourselves;

6.5.2 communicate with us as necessary in connection with our affairs and generally in connection with our investments with International Wealth;

6.5.3 provide personal data to such third parties as International Wealth may consider necessary in connection with our affairs and generally in connection with our investments with International Wealth including to third parties outside Mauritius;

6.5.4 without limitation, provide such personal data to the Financial Advisor, notwithstanding that any such party may be outside Mauritius;

6.5.5 transfer personal data to other companies within the same group as International Wealth (including to any such companies which are outside Mauritius), including by means of electronic communications;

7. I/We declare that the information provided in this application and any additional documentation is true and complete to the best of my/our knowledge and that I/We agree to provide additional information if requested by International Wealth.

7.1 I/We understand our rights as Data Subjects as detailed in International Wealth’s Data Protection and Privacy Policy and that I/we have the rights to:

7.1.1 on written instruction, request International Wealth to provide us/me, without excessive delay and free of charge, confirmation as to whether or not personal data relating to ourselves is being processed and a copy of the data processed.

7.1.2 on written instruction, request International Wealth to provide me/us with details of how it protects our personal data.

7.1.3 on written instruction, request International Wealth to restrict the use of our personal data.

7.1.4 on written instruction, request International Wealth to amend any personal data it holds on ourselves.

7.1.5 on written instruction, request International Wealth to destroy the Data held on ourselves (unless the keeping of said Data is required by Law).

8. I/We declare that the information provided in this application and any additional documentation is true and complete to the best of our knowledge and that we agree to provide additional information if requested by International Wealth.

9. In providing International Wealth with information, i/we hereby represent and warrant to International Wealth that i/we have obtained the consent of any data subjects other than ourselves to the International Wealth holding and using their personal data for the purposes other than the purpose set out above (including the explicit consent of the data subjects for the processing of any sensitive personal data for the purposes set out above) and that we will use our best endeavours to obtain the consent of the data subjects to International Wealth and using personal data for the processing of any personal data for the purpose set out above. For the purposes of this application form, “data subject”, “personal data” and “sensitive personal data” shall have the meanings attributed to them in the Data Protection Law.

10. I/We understand that International Wealth does not provide legal/tax or financial advice and it is our responsibility to seek independent legal/tax or financial advice before completing the application form.

11. I/We declare that all monies transferred to International Wealth or its agents/delegates come from legitimate sources and agree to further justify the source of the funds to International Wealth on request.

12. I/We understand that I/We are solely responsible for investments in International Wealth, the value of which may rise or fall and that there is no financial guarantee against loss of investment.

13. I/We hereby authorise International Wealth to accept facsimile/e-mail/other electronic documents and instructions regarding our International Wealth Portfolio Bond (hereafter referred to as ‘electronic documents and instructions’). I/We accept that if I/We suffer any loss as a result of International Wealth’s acceptance or interpretation of any electronic documents and instructions coming from or purporting to come from me/us or our Financial Advisor, I/We shall have no claim against International Wealth. I/We further agree to indemnify International Wealth against any claims, demands, proceedings or actions which may be brought against International Wealth (by any person, including us) and against any liabilities, costs, charges, losses or expenses incurred directly or indirectly by International Wealth as a result of it acting in accordance with any electronic documents and instructions given (other than where there is fraud, gross negligence or wilful misconduct on the part of International Wealth or its officers or employees).

14. I/We agree to this policy being governed by Mauritius law and to the Courts in Mauritius having the right to decide any case that may be brought in relation to this policy.
PLEASE TICK BELOW*
- I have read and understand the declaration above
Financial Advisor's Signature
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
First Applicant Online Signature*
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date*
DD slash MM slash YYYY

SECTION 7 : RISK DISCLOSURE
Please carefully read through the following declaration before accepting.

In connection with the purchase of the financial instruments listed above, I/we the undersigned policyholder/applicant/s declare that:
1. I/We understand that we are solely responsible for reviewing any investment into any fund, share, ETF, interest in a certificate, note or debenture or other security or financial instrument, its offering and any statements made by an investment manager, sponsor or promoter and for performing such due diligence as we may deem appropriate, including consulting our own legal and tax advisers, and that any information provided by International Assurance Limited PCC (“IAL”) shall not form the basis of our investment decision.
2. I/We understand that any investment promotional material, including brochures, leaflets or fact sheets, presented to us have been provided by our Financial Advisor and are not from IAL. IAL does not represent that such material is accurate, complete, and/or up-to-date and, if applicable, time indicated nor does IAL not accept any responsibility to update any opinion, analyses or other information contained in the material. The material presented to us has been provided by our Financial Advisor is for my/our information only and is not an offer or solicitation to buy or sell any investment into any fund, share, ETF, interest in a certificate, note or debenture note or other security or financial instrument.
3. I/We understand that some investments may not be appropriate for us. These investments can be speculative and may involve a high degree of risk, above and beyond those associated with traditional asset class investments and we could lose all or a substantial amount of our investment. Many investments have eligibility requirements for participation, generally only available to high net worth individuals and professional investors.
4. I/We understand that some investments are not regulated, are not collective investment schemes and are not subject to the same regulatory requirements as collective investment schemes. Some investments may use leverage and other speculative investment practices that may increase the risk of capital loss. These investments may have performance that is volatile and may hold investments that are illiquid.
5. I/We acknowledge that we have been made aware by our Financial Advisor of the risks associated with the financial instruments listed above and accept all of the aforesaid risks which may result in financial loss and hereby waive and abandon any right to hold IAL responsible therefore.
6. I/We agree that IAL is hereby indemnified against any loss or damage suffered by us in connection with the said purchase/s as described above.
7. I/We acknowledge that the financial instruments listed above may have a charging structure that might include various fees and commissions and that these have been disclosed by our Financial Advisor to us.
8. I/We agree that I/we will remain liable for any and all of the international Wealth's administrative and policy fees during any period in whicg the purchase, sale, transfer, trade of and/or investment in any investment instrument that is suspended or impaired in any manner wharsoever.
PLEASE TICK BELOW:*
- I have read and understand the declaration above
Financial Advisor's Signature
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
First Applicant Online Signature*
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date*
DD slash MM slash YYYY

SECTION 8: SIGNATURES
I/We the undersigned hereby confirm our acceptance of and having read and understood this application.

I/We the undersigned agree to the following documents forming the basis of the contract between me/us and International Wealth:
- this Application Form
- the Terms and Conditions
- the Policy Schedule
- any Endorsements to the Policy Schedule
Financial Advisor's Signature
Upon receipt of emailed contract, please sign here using your Digital ID (including a Digital Date and Time Stamp and Location Confirmation) created in and using Adobe Acrobat
First Applicant Online Signature*
Second Applicant's Signature
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY
Date
DD slash MM slash YYYY

SECTION 9: PAYMENT DETAILS
Payment Method
Please select the appropriate payment method:*
- Share Transfer
- Telegraphic Transfer
- BTC
Investor Banking Details
Name of Bank
Country
Address of Bank
Account Name
Account Number
SWIFT / BIC
IBAN CODE
Amount in USD
Amount in Words
Transfers to the applicant will only be transferred to the above-mentioned account.

Telegraphic Transfer: Payment

Please pay to
NAME OF BANK	THE MAURITIUS COMMERCIAL BANK
ADDRESS OF BANK	SIR WILLIAM NEWTON STREET, PORT LOUIS, MAURITIUS
COUNTRY	MAURITIUS
ACCOUNT NAME	INTERNATIONAL ASSURANCE LIMITED PCC
SWIFT/BIC	MCBLMUMU

Reference (Name)
Please tick the appropriate currency and account:*
- GBP
- EUR
- USD
- AUD
- SGD
- BTC

PLEASE TAKE NOTE OF THE APPROPRIATE ACCOUNT NUMBERS BELOW:

CURRENCY	ACCOUNT NO.	IBAN
GBP	000011857161	MU05MCBL0901000001857161000GBP
EUR	000011857188	MU11MCBL0901000001857188000EUR
USD	000011857013	MU76MCBL0901000001857013000USD
AUD	000442874855	MU69MCBL0944000442874855000AUD
SGD	000442874863	MU58MCBL0944000442874863000SGD
BTC	WALLET	36hNth78zzjqrTwELB8ShpRiLm5ie2DcbP

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