Prestige International Investment Plans · Application Form Producer Code ... please include an...

INTERNATIONAL

Prestige International Investment Plans

Application Form

Application Checklist

FF Illustration signed by the Participant(s)

FF If printed policy documents is selected, a USD 45 fee is required.

FF Participant(s) is not a resident or citizen of the USA and/or BVI. Must provide proof of residence (e.g., a utility bill - no more than three months old).

FF Participant(s) Valid Proof of Identity (e.g., copy of official government I.D.)

FF Completed “Payment Authorization Form” (if applicable)

FF Completed “Source of Funds Questionnaire” (if applicable)

Application Form

Producer Code

Producer Name

Premier Trust Application_Prestige_111016.indd 1 11/10/16 11:43 AM

You should view your unit-linked policy as a long-term investment. Early surrender/withdrawal of funds from your policy will result in penalty charges and the possibility of your original investment goals not being satisfied. Prior to purchasing this product, please ensure that you fully understand all of the terms of the policy including the charges and possible penalties that could apply in the event of early surrender/withdrawal. Please make sure you understand how this policy satisfies your investment goals and why it is suitable for you, before you decide to purchase.

All Policies are issued by Premier Assurance Group SPC Ltd.

FILLING IN THIS APPLICATION FORM

Please complete all required information. Failure to provide all relevant information may result in a delay on the processing of your Application Form.

The information provided on this document is not intended for distribution to, or use by, any person in the United States or in any jurisdiction or country where such distribution or use would be contrary to law or regulation or which would subject Premier Trust, or any of Premier Trust’s products, services or affiliates to any authorization, registration, licensing or notification requirement within any jurisdiction in Europe, Middle East, Asia, Latin America, the Caribbean, or elsewhere.


PT_111016

Enrollment Agreement Between:

1) Premier Trust (the “Trust”) and2) Each Plan Participant (as hereinafter defined)

Name of Employer

A. PARTICIPANT INFORMATION

For inquires write to: [email protected]

Or

Premier Trust 4th Floor Rodus Building, Road Reef

P.O. Box 765, Road Town, Tortola, British Virgin Islands

Principal Residential Address

Postal CodeCountry

City State/Province

Occupation Age

SexM F

Marital Status Married Single Divorced Widow

Date of Birth Month Day Year

Employer Address

State/Province Country Postal Code

City

Passport/Gov’t ID #Citizenship

The Plan Participant or Legal Entity

Middle NameFirst Name Last Name Mr. Mrs. Ms.

*Only if applicable, otherwise default to English.Preferred Language* English Spanish

Email

Place of Birth Town/City CountryState/Province

Telephone (Primary)Area CodeCountry Code

Telephone(s) Type Residence Business Mobile Fax

Telephone (Other)Area CodeCountry Code

Type Residence Business Mobile Fax

3


PT_111016

C. PLAN INFORMATION

B. JOINT PLAN PARTICIPANT

(the “Joint Plan Participant”) (the First Plan Participant and the Joint Plan Participant, together, the “Plan Participants”).

Please select your charging option:(Only applicable for the producer, and only for Index Reserve, Higher Education Plan, Provest 10 Principal Protection and New Horizon Plans.)

PRODUCER USE ONLYOption A

Option C

Option B

Option D

Principal Residential Address

Postal CodeCountry

City State/Province

The Joint Plan Participant Middle NameFirst Name Last Name Mr. Mrs. Ms.

SexM F

Marital Status Married Single Divorced Widow

Date of Birth Month Day Year

Occupation Relationship to Participant

Name of Employer

Employer Address

State/Province Country Postal Code

City

Plan Name Plan Name Number of YearsNumber of Years

*OPTIONAL (For Prestige Wealth Builder only)If the Participant wishes to delegate the selection of investment funds to his or her financial advisor, please select a quarterly investment advisory fee below. This fee will be deducted quarterly in arrears from the plan cash value.

REGULAR CONTRIBUTION PLANS LUMP SUM CONTRIBUTION PLANS

0.0625% 0.1250% 0.1875% 0.2500%

Passport/Gov’t ID #Citizenship

*Only if applicable, otherwise default to English.Preferred Language* English Spanish

Email

Place of Birth Town/City CountryState/Province

Telephone (Primary)Area CodeCountry Code

Telephone(s) Type Residence Business Mobile Fax

Telephone (Other)Area CodeCountry Code

Type Residence Business Mobile Fax

25

10

25

10

15

Provest Plan

Provest 10 Principal Protection

Provest Principal Protection

New Horizon

Prestige Index Reserve 10 2015

Prestige Higher Education

Prestige Wealth Builder * 5 7 10

5 7 10

5 7 10

Premier Principal Protection

Premier Principal Protection Plus

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PT_111016

D. DOCUMENTATION TYPE AND DELIVERY METHOD

Electronic Policy Documents

(Free of charge. Receive your documents faster by selecting this option.)

Printed Policy Documents Delivered to My Producer

(Requires a USD 45 fee)

E. PLAN PAYMENT OPTIONS

PLAN CONTRIBUTION AMOUNT

Please select your plan currency

GBP EUR AUD *USD

Contribution

*Not available for Provest Plan and Premier Plan.

Monthly Quarterly Semi-Annual Annual Lump-Sum (For Prestige Wealth Builder and Premier Principal Protection only)

Payment Frequency

Printed Policy Documents Delivered to My Agency

(Requires a USD 45 fee)

PAYMENT OPTIONS

Check/Credit Card Payments

Payment will be debited on the 7th or the 20th of the month based on the effective date assigned to the plan.

If the plan participant or joint participant is not the credit card holder, a separate “Payment Authorization Form” must be completed.

No Check/Credit Card fee will be applied to any Provest Plans. A 1.5% Credit Card fee will be applied to all Premier Plans.

Credit Card Type

Payment Frequency

Monthly Quarterly Semi-Annual Annual

Payment Amount

First payment Future recurring payments

Card Number Expiration Date

Month Year

I hereby authorize the Trust to initiate recurring debits to my account according to the payment frequency selected. I acknowledge that I am the account owner and authorize all of the above as evidenced by my signature below:

Name of Account Holder Billing Address

Signature

Payment Authorization

Verification Number (CVV)

AMEXOPTIMA

AMEX STAND.

AMEXBLUE

MCVISA

For New Horizon plans, please indicate your initial rollover amount

Please make checks payable to LYNCPAY, LLC. Checks accepted in USD only.Check

Please complete the Wire Transfer Form to process payment.Wire Transfer Instructions

Please remit plan amount net of wire transfer fees. If you have elected to receive a printed copy of your Policy Documents, please include an additional USD 45.00 application fee.

Wells Fargo and UBS are providers of investment services and act as Global Custodians to the Premier Assurance Segregated Portfolio. Wells Fargo and UBS, or any of their subsidiaries acting as Global Custodian in no way guarantee investment performance of mutual funds selected by the Participant(s).

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PT_111016

The Plan Participant hereby makes the following selection of funds/indices. Please mark a percentage amount next to the fund(s)/index(es) selected.

F. SELECTION OF CUSTODIAN AND FUNDS

Fund Number

Please consult the “Investment Fund Selection” sheet to complete your fund choices.

For Provest Plan Only: Please select a maximum of five (5) funds with minimum allocation of 10% per fund. For Premier Plan Only: Please select a maximum of ten (10) funds with minimum allocation of 10% per fund.

Note: You must choose from the list of funds specific to the currency selected.

For Provest Plan and Premier Plan only: Please select one (1) of the following Global Custodians:

Fund Family Fund Name Percentage

%

%

%

%

%

%

%

%

%

%

SELECTION OF FUNDS

Wells Fargo UBS

For plans with Principal Protection only. Global Custodian: Union Bank of Switzerland (UBS)

PRINCIPAL PROTECTED OPTIONS

For Principal Protection Plans only: Please select up to five (5) indices with minimum allocation of 20% per index.

TOTAL PRECENTAGE INVESTED MUST EQUAL 100%

INDICES FOR USD/AUD CURRENCY

Percentage to be invested in index

Index Name

%

%

%

%

%

INDICES FOR GBP CURRENCY


Index Name

%

%

%

%

%

INDICES FOR EUR CURRENCY


Index Name

%

%

%

%

%

6


PT_111016

The Plan Participant hereby designates the following as Primary and Contingent Beneficiaries. Up to four (4) primary beneficiaries may be selected, however, the percent allocated combined must equal 100%.

G. DESIGNATION OF BENEFICIARIES

H. TAX RESIDENCY SELF-CERTIFICATION

PRIMARY BENEFICIARY(IES)Full Name Relationship Date of Birth ID Number Percentage

1Month Day Year

%

2Month Day Year

%

3Month Day Year

%

4Month Day Year

%

INQUIRY REGARDING U.S. STATUS

Is any of the aforementioned beneficiaries a U.S. citizen or resident, subject to U.S. taxation or otherwise meet the “substantial presence” test* described below?

Yes No

Is any of the Plan Participants a U.S. citizen or resident, subject to U.S. taxation or otherwise meet the “substantial presence” test* described below?

Yes No

*To meet the “substantial presence” test, the individual must be physically present in the United States on at least:

§ 31 days during the current year; and

§ 183 days during the 3-year period that includes the current year and the 2 years immediately before that, counting:

- All the days you were present in the current year, and

- 1/3 of the days you were present in the first year before the current year, and

- 1/6 of the days you were present in the second year before the current year.

CONTINGENT BENEFICIARY(IES)Full Name Relationship Date of Birth ID Number

1Month Day Year

2Month Day Year

The BVI International Tax Authority (ITA) and the Cayman Islands Tax Information Authority in compliance with the OECD Common Reporting Standard (CRS) and the US Foreign Account Tax Compliance Act (FATCA) require our organization to collect and report certain information about each Plan Participant’s tax residence.

Please complete the sections below and provide any additional information that may be requested. Please note that we may be obliged to share this information with the relevant tax authorities.

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PT_111016

H. TAX RESIDENCY SELF-CERTIFICATION (Continued)

PARTICIPANT DECLARATION OF FOREIGN TAX RESIDENCY (EXCLUDING THE U.S.)

Additional Declarations

Country Tax Identification Number (TIN)If no TIN available enter Reason A, B, or C

1

If you selected Reason B, please explain why you are unable to obtain a TIN


2



3


Please complete the following table indicating (i) where the Account Holder is tax resident and (ii) the Account Holder’s TIN for each country/jurisdiction indicated. If the Account Holder is tax resident in more than three countries/jurisdictions, please use a separate sheet. If a TIN is unavailable please provide the appropriate reason A, B, or C where indicated below:

Reason A: The country/jurisdiction where the Account Holder is resident does not issue TINs to its residents

Reason B: The Account Holder is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason)

Reason C: No TIN is required. (Note. Only select this reason if the domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction)

I hereby confirm that I am, for tax purposes, resident in the following country(ies):

8


PT_111016

H. TAX RESIDENCY SELF-CERTIFICATION (Continued)

JOINT PARTICIPANT DECLARATION OF FOREIGN TAX RESIDENCY (EXCLUDING THE U.S.)

Additional Declarations


1



2



3


Please complete the following table indicating (i) where the Account Holder is tax resident and (ii) the Account Holder’s TIN for each country/jurisdiction indicated. If the Account Holder is tax resident in more than three countries/jurisdictions, please use a separate sheet. If a TIN is unavailable please provide the appropriate reason A, B, or C where indicated below:

Reason A: The country/jurisdiction where the Account Holder is resident does not issue TINs to its residents

Reason B: The Account Holder is otherwise unable to obtain a TIN or equivalent number (Please explain why you are unable to obtain a TIN in the below table if you have selected this reason)

Reason C: No TIN is required. (Note. Only select this reason if the domestic law of the relevant jurisdiction does not require the collection of the TIN issued by such jurisdiction)

I hereby confirm that I am, for tax purposes, resident in the following country(ies):

9


PT_111016

To be completed by Plan Participant(s) to be insured. If you answer “Yes” to questions 1, 2 and/or 5, please provide details in the comment box below.

Yes No Yes No

1. Have you been hospitalized in the last 6 months or has a surgery been recommended or performed?

2. Have you ever applied for an insurance policy that was rated-up, declined or postponed?

3. Are you presently working at least 20 hours per week?

4. Have you been working at least 20 hours per week for the last two months?

5. Have you ever been told that you suffer from, or have been treated for, or prescribed medication for, any chronic condition such as diabetes or a serious condition such as cancer?

I. SOURCE OF FUNDS

Plan Participant Comments Joint Participant Comments

J. LIFE INSURANCE QUESTIONNAIRE

This section must be completed by all cases with a single contribution amount of USD/EUR/GBP/AUD 10,000 or above. Additionally, for cases in which a single contribution amount is equal to or exceeds USD/EUR/GBP/AUD 250,000 an additional “Source of Funds Questionnaire” is required to be completed.

I have known the Plan Participant since (date)2. MM/DD/YYYY

Participant’s bank information3.

a. Bank Name

MM/DD/YYYYb. Bank Address

c. Account No.

d. Date Account Opened

5. What is the purpose of this investment (retirement, education, etc.)?

Plan Participant Joint Plan Participant

The Plan Participant was referred by1. Name Relationship

4. Please indicate how funds were obtained for this investment

f. Liquidation of other Investment, Insurance Plan

d. Inheritance e. Borrowed

g. Gift

a. Current Income c. Sale of asset or propertyb. Savings

h. Other Please Specify

10


PT_111016

WHEREAS

(A) The Trustees have established the Trust under section 84 A of the Trustee Act of the British Virgin Islands

(B) Under the terms of the Trust the Trustees shall purchase one or more policies of insurance from the Insurance Company with monies received from Plan Participant(s)

(C) For each Plan Participant a separated Sub-fund shall be constituted under the Trust for the benefit of the respective Beneficiaries named by the Plan Participant

(D) The Trustees shall direct the Insurance Company to invest the premium payments paid from each Sub-fund in the investment funds specified by the relevant Plan Participant

(E) The Trustees shall administer the Plan in accordance with the terms of the Trust and both the selection of the Investment Plans and the Beneficiaries and the mode of distribution of their benefits shall be set as forth by the Plan Participant(s) in the Enrollment Agreement

NOW IT IS HEREBY AGREED AS FOLLOWS:

1. DEFINITIONS AND INTERPRETATION

(a) In this Enrollment Agreement save as expressly herein defined and where the context admits the definitions and rules of the construction contained in the Trust shall apply

(b) In this Enrollment Agreement where the context admits the following terms and expressions shall have the following meanings:

(i) “Beneficiaries” means the persons listed in Section G of this Enrollment Agreement

(ii) “Insurance Company” means Premier Assurance Group SPC, Ltd.

(iii) “Investment Plans” means the investment funds in which the Trustees direct the Insurance Company to invest the premium payments paid from the Sub-fund relating to the Plan Participant

(iv) “Plan” means the scheme whereby the Trustees purchase policies for the benefit of the Beneficiaries with monies received from the Plan Participant(s) (as set out in the Second Schedule to the Trust)

(v) “Policies” means the insurance policies purchased from the Insurance Company in accordance with the terms of the Plan

(vi) “Sub-fund” means the separate fund established under the terms of the Trust for each Plan Participant

(vii) “Segregated Portfolio” means Premier Assurance Segregated Portfolio

(viii) “Time of Maturity” means the date on which the Investment Plans mature

(ix) “Trust” means the Declaration of Trust made between Sable Trust Limited and PA Marketing Ltd on February 14, 2006 and the Trust therein declared

2. REPRESENTATIONS AND WARRANTIES

The Plan Participant hereby declares represents and warrants as follows:

(a) That the information provided in this Enrollment Agreement is accurate and complete (2) that a copy of the Trust has been provided to the Plan Participant (3) that the Plan Participant desires to participate in the Trust and directs the Trustees establish a Sub-fund of the Trust for the benefit of the Beneficiaries and (4) that the Plan Participant directs the Trustees to invest the Sub-fund assets in a Policy issued by the Insurance Company on behalf of the Segregated Portfolio

(b) That the Plan Participant(s) has read carefully this Enrollment Agreement the Trust and the form of the Policy to be entered into between the Trustees and the Insurance Company

(c) That it has been explained to the Plan Participant and the Plan Participant(s) fully understands that the person having the standing to enforce the Trust is the Enforcer

(d) That the Plan Participant(s) takes full responsibility for the selection and choice of Investment Plans

(e) That the Plan Participant(s) has seen and signed the Plan Illustration attached to this Enrollment Agreement

(f) That the Plan Participant(s) is not a citizen of the United States of America or of the British Virgin Islands

(g) That the Plan Participant(s) has not contributed and will not contribute to the Trust any illegally obtained funds

(h) That the Plan Participant(s) appreciates that all funds must be sent directly to the Trustees either by check, wire or credit card payment and that any funds given to any intermediary will be at the Plan Participant’s sole risk

3. FRAUDULENT DISPOSITIONS

In respect of each transfer of monies or other property to the Trustees the Plan Participant(s) hereby warrants for each transfer that each transfer does not and will not at the time made constitute transfers which are void voidable or impeachable by virtue of this Statute of Elizabeth (13 Eliz CV) of 1571 by virtue of Parts VIII and XIV of the Insolvency Act 2003 of the British Virgin Islands by virtue of section 81 of the Conveyancing and Law of Property Act of the British Virgin Islands by virtue of section 40 of the Matrimonial Proceedings and Property Act of the British Virgin Islands or by virtue of any other law relating to fraudulent conveyances or fraudulent preferences or transfers to defeat bona fide purchasers.

4. THE DEED OF DECLARATION OF TRUST

The Plan Participant(s) acknowledges that a copy of the Trust has been provided to the Plan Participant(s) and the Plan Participant hereby agrees that he shall be subject to all of the provisions of the Trust and this Enrollment Agreement which are hereby made binding on the Plan Participant (as if inter alia he were a party to the Trust in addition to being a party to this Enrollment Agreement).

5. PURCHASE OF THE INVESTMENT PLAN

The Plan Participant(s) agrees that the Trustees shall with monies received from the Plan Participant(s) purchase one or more Policies and shall continue to pay the premiums due thereon so long as monies are available in the Sub-fund.

6. PAYMENTS TO THE TRUSTEES

The Plan Participant(s) agrees to opt for the method of payment to the Trustees as is set out immediately below in this Enrollment Agreement provided that such method may be changed by the Participant(s) if agreed to by the Trustees after written notice requesting a change has been given to the Trustees by the Plan Participant(s).

Payment method: is stated in Section E of this Enrollment Agreement.

7. THE BENEFICIARIES

The names of the Beneficiaries are listed in Section G of this Enrollment Agreement.

At any time and from time to time upon receipt by the Trustees of a written notice signed by the Plan Participant(s) Beneficiaries may be deleted or added (or the order of their potential benefit may be changed) by the Plan Participant(s).

If there are surviving Primary Beneficiaries at the time of the distribution of the Sub-fundpayment the monies held in the Sub-fund shall be paid to the surviving Primary Beneficiaries in proportion to the percentage entitlements of such Primary Beneficiaries as set out in this Enrollment Agreement (such that if there is only one surviving Primary Beneficiary such surviving Primary Beneficiary shall receive all monies held in the Sub-fund).

If there are no surviving Primary Beneficiaries at the time of distribution of the Sub-fundpayment the monies held in the Sub-fund shall be paid to the Contingent Beneficiaries inproportion to the percentage entitlements of such Contingent Beneficiaries as set out in this Enrollment Agreement (such that if there is only one surviving Contingent Beneficiary such surviving Contingent Beneficiaries shall receive all monies held in the Sub-fund).

8. DEFAULT IN CONTRIBUTION PAYMENTS

If the Plan Participant(s) fails to make any contribution due hereunder within 30 days of written notice from Trustees that a payment is overdue subject to the discretion of the Trustees and the Insurance Company the Policy will lapse and any value in the Policy shall be paid to the Beneficiaries at such time as the Trustees receive the same from the Insurance Company.

9. INVESTMENT SELECTIONS

To the extent that any Policy enables a choice of investments for a Sub-fund the Trustees shall make such investments in accordance with the wishes of the Plan Participant(s) as outlined in this Enrollment Agreement.

Changes in investment selection may be made at any time and from time to time by the Plan Participant(s) as permitted by the Insurance Company the Investment Plans and the Trustees.

10. REVOCATION

The Plan Participant(s) may give notice of revocation to the Trustees at any time followingwhich the Trustees will surrender the Policy in as far as it relates to the Sub-fund to which such notice relates whereupon the Sub-fund shall vest in the Plan Participant(s) absolutely.

The payment and timing of payments of any benefits to the Plan Participant(s) following such revocation will depend upon the redemption value of the Policy (in as far as it relates to the Sub-fund) and the receipt of funds in respect thereof from the Insurance Company.

K. ENROLLMENT AGREEMENT

11


PT_111016

11. CONFIRMATION OF REPRESENTATIONS AND WARRANTIES / INDEMNITY

The Plan Participant hereby confirms the accuracy of all information and the validity of allrepresentations and warranties provided to the Trustee in connection with the Plan and/or the subscription for Investment Plan and for the Policy howsoever provided including thosecontained in Clause 2 of this Enrollment Agreement and the contents of any personal ormedical questionnaire (together the “Representations & Warranties”).

The Plan Participant acknowledges that some of this information will be provided to issuers of the Policy and that any inaccuracy therein may result in the invalidity of such Policy or the related Investment Plans and the loss of all monies paid in relation thereto.

The Plan Participant hereby covenants to inform the Trustees of any change in any matter that forms the subject of any of the Representations & Warranties.

The Plan Participant hereby covenants to indemnify and hold harmless the Trustees (and their directors and officers) against any loss or damage (including legal fees) occasioned by any inaccuracy in any Representations & Warranties or failure to advise the Trustees of any change in any matter that forms the subject of any of the legal Representations & Warranties.

The Plan Participant agrees that the Trustees shall be entitled to rely on and to act inaccordance with any written instructions purported to be provided by the Plan Participant and the Plan Participant hereby undertakes to indemnify and hold harmless the Trustees (and their directors and officers) against any loss or damage (including legal fees) occasioned by the Trustees acting in accordance with any such instructions.

12. PAYMENT OF BENEFITS

The Trustees shall ensure that payments are made to the Beneficiaries in respect ofproceeds received from the Insurance Company in accordance with the terms hereof on the tenth day of the month following the receipt thereof.

13. FEES AND EXPENSES

The Trustees shall charge its fees and expenses as provided in the Trust.

14. VERIFICATION OF THE IDENTIFICATION AND SOURCE OF FUNDS

As part of the Trustees’ responsibility for the prevention of money laundering the Trustees and their affiliates subsidiaries or associates will require a detailed verification of each PlanParticipant’s identity and the source of the subscription funds.

15. FOREIGN ACCOUNT TAX COMPLIANCE ACT (FATCA)

If the Plan Participant becomes a U.S. Citizen or resident, then the Plan Participant hereby acknowledges and agrees that if a payment made to a Beneficiary by the Trustees or the Insurance Company in connection with the Trust, the Policies, Investment Plans, Sub-fund or any products or services provided to the Plan Participant or Beneficiaries (as applicable) hereunder would be subject to U.S. federal withholding tax imposed by the Foreign Account Tax Compliance Act, including Sections 1471 through 1474 of the Internal Revenue Code of 1986, as amended (the “Code”), any current or future regulations or official interpretations thereof and any agreements entered into pursuant to Section 1471(b)(1) of the Code (collectively, “FATCA”), the Plan Participant or Beneficiaries (as applicable) shall deliver to the Trustees at the time or times prescribed by law and at such time or times requested by the Trustees such documentation requested by the Trustees as may be necessary for the Trustees or the Insurance Company to comply with their obligations under FATCA, to determine that the Plan Participant or Beneficiaries (as applicable) has complied with their obligations under FATCA or to determine the amount to deduct and withhold from such payment. The Plan Participant further agrees to immediately notify the Trustees of a change in circumstances (as such term is defined in FATCA) with respect to status of the Plan Participant or Beneficiaries (as applicable) and provide the Trustees with such information and/or documentation requested by the Trustees (including a written statement or updated withholding certificate) at the time or times prescribed by law and at such time or times requested by the Trustees. The Trustees, the Insurance Company and their respective officers, directors, employees and agents shall not at any time incur any liability to the Plan Participant or the Beneficiaries (and each hereby expressly waive and release any and all claims and causes of action which they may at any time have against the Trustees, the Insurance Company and their respective officers, directors, employees and agents) in connection with any acts, omissions, or circumstances at any time or times arising out of or relating to any of the obligations of the Trustees, the Insurance Company or their affiliates with respect to FATCA, including, as applicable, reporting of information or withholding on any payments received or originated by the Plan Participant or Beneficiaries (as applicable).

16. TRUSTEES’ INDEMNITY

The Trustees and the Enforcer are provided with a comprehensive indemnity in the Trust against any loss to the Trust Fund or any Sub-fund as described in the Trust.

17. GOVERNING LAW

This Enrollment Agreement shall be governed and construed in accordance with the laws of the British Virgin Islands.

K. ENROLLMENT AGREEMENT (Continued)

12


PT_111016

To Sable Trust Ltd.:

(1) Represent that the information provided in the Enrollment Agreement is accurate and complete. (2) Acknowledge that a specimen copy of the Premier Trust has been provided to me.(3) Desire to participate in the Trust and direct the Trustee of the Trust establish a Sub-fund of the Trust for

the benefit of the Plan Participant and Beneficiaries; and

(4) Direct the Trustee to invest the Sub-fund assets in a Policy issued by the Insurance Company on behalf of the Segregated Portfolio.

I have read carefully this Enrollment Agreement, the Trust Deed and the form of the Policy to be entered into between the Trust and the Insurance Company.

It has been explained to me, and I fully understand, that the only person or persons having the standing to enforce the Trust are enforcers of the Trust from time to time and that neither in my capacity as a settlor nor in my capacity as a beneficiary of the Trust do I have any standing to enforce the Trust or bring any action for the enforcement of the duty of the enforcer to enforce the Trust.

- I take full responsibility for the selection and choice of Investment Plans made by me or my financial advisor. - I have seen and signed the Plan Illustration, attached to this Enrollment Agreement. - I am not a citizen of the United States or of the British Virgin Islands, and meet the requirements specified in

the “substantial presence” test. - I have not and will not contribute to the Trust any illegally obtained funds. - I hereby acknowledge that all funds must be sent directly to the third-party administrator of the Trust either

by check, wire or credit card payment and that any funds given to any intermediary will be at my sole risk.

I:

This DEED was executed by the Plan Participant(s) and the Trustees this , day of 20

Executed and Delivered as A Deed by

Print name here - Plan Participant Plan Participant Signature

Joint Plan Participant SignaturePrint name here - Joint Plan Participant

Authorized Corporate Official Signature Print name here - Authorized Corporate Official

In the presence of

Print name here - Producer (Witness)

I hereby certify that I have personally met with the Plan Participant(s) and verified his/her/their original identification documents. I declare that to the best of my knowledge and belief, the Plan Participant(s) is/are of good standing and the information given in the Enrollment Agreement and questionnaires is true and complete.

Producer Code Producer Signature

13


Prestige International Marketing Services Ltd90 Main Street, PO Box 3099, Road Town, TortolaBritish Virgin IslandsT: +44 (0) 203 178 4055F: +44 (0) 203 004 9690 E: [email protected]: www.prestige-IMS.com

NOTE: This document is issued by Prestige International Marketing Services Ltd., and approved as financial promotion for information purposes only and underwritten and administered by Premier Trust’s service providers. The information provided within this brochure is not intended for distribution to, or use by, any person in the United States or in any jurisdiction or country where such distribution or use would be contrary to law or regulation or which would subject Premier Trust products, services or affiliates to any authorization, registration, licensing or notification requirement within any jurisdiction. Past performance is no guide to future results. Investments can go up as well as down. No representation is being made that any investment Trust/s described within this document will or is likely to achieve any profits or losses similar to those shown. Changes in foreign exchange rates may have an adverse effect on the value or price of the investment. Any track record/s and performance data shown is based on the actual results published by the Underlying Investment Advisor/s within the Trust/s, which were in existence at the time of creation but should not be relied upon when making a decision to invest. If you are uncertain with regards to your eligibility you should seek professional advice in this respect. This document does not constitute an offer to sell or a solicitation of an offer to buy shares in any Trust/s or investment portfolios. Neither Prestige International Marketing Services Ltd., nor Premier Trust accept any liability from investors who rely upon any other information with regard to any Trust/s or investment portfolio. All trading strategies are denominated in USD$ unless otherwise state. Investment allocation scenarios shown are for example only and are subject to change and will also vary from time to time. The MSCI EAFE Index is a registered trademark of Morgan Stanley Capital International. The S&P 500 Index is a registered trademark of Standard & Poors Group. UBS and the UBS Key logo is a registered trade mark of Union Bank of Switzerland. Sable Trust and the Sable Trust logo is a registered trade mark of Sable Group. None of the companies listed within this document recommend, approve or endorse the use or economic viability of this product or any of the statements made within this document. The Investment Trust/s or investment portfolios and or services offered or described within this document are marketed through Prestige International Marketing Services Ltd., a company incorporated in the British Virgin Islands. BVI Business Companies are exempt from the BVI income tax, from tax on dividends, interest, royalties, compensations and other amounts paid by a company; also they are exempt from all the capital gains, estate, inheritance, succession or gift tax with respect to any shares, debt obligations or other securities of the BVI IBC’s. The companies are exempt from any kind of stamp duties relating in any way to its assets or activities, with an exception for land ownership transactions in the BVI: in that case stamp duty remains payable. Individuals should seek their own independent tax advice. It is the responsibility of all Users to be informed and to observe all applicable laws and regulations of any relevant jurisdiction, and to satisfy themselves that their use of this information and any subsequent Trust/s or investment portfolio is permissible under the applicable laws, rules and regulations of any applicable government, governmental agency, or regulatory organization where they reside. Further information on facts and figures contained within the document is available upon request. © 2017

INTERNATIONALPremier Trust

4th Floor Rodus Building, Road Reef, P.O. Box 765,

Road Town, Tortola, British Virgin Islands

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Last Modified: July 20, 2017 8:34 AM

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