FORM IN102-2 version 05/ SUBSCRIPTION AGREEMENT ACUERDO DE SUBSCRIPCIÓN

Transcripción

1 FORM IN SUBSCRIPTION AGREEMENT ACUERDO DE SUBSCRIPCIÓN May / Mayo 2015

2 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. This is a long-term commitment so make sure you understand how this policy satisfies your investment goals and why it is suitable for you, before you decide to purchase the choice is yours. All Policies are issued by the Investors Trust Segregated Portfolio of Investors Trust Assurance SPC, a Cayman Islands segregated portfolio company. Usted debe ver su póliza como una inversión a largo plazo. Un rescate/retiro anticipado de fondos de su póliza resultará en cargos de penalidad y la posibilidad de no cumplir sus metas de inversión satisfactoriamente. Antes de adquirir este producto, asegúrese de entender completamente todos los términos de la póliza, incluyendo los cargos y posibles penalidades que puedan ser aplicados en el evento de un rescate/retiro anticipado. Este es un compromiso a largo plazo, por lo tanto es muy importante que entienda cómo esta póliza responde a sus objetivos de inversión y por qué es conveniente para usted, antes de decidir su compra - la elección es de usted. Todas las pólizas son emitidas a través de Investors Trust Segregated Portfolio de Investors Trust Assurance SPC, una compañía de portafolio segregado de las Islas Caimán. FILLING IN THIS FORM / Como completar este Acuerdo de Subscripción This document is intended to be made available only in jurisdictions in which this insurance product is permitted to be offered or sold to and shall not be construed as an offer to sell or a solicitation to buy or a provision of insurance in any other jurisdiction. The company does not offer or sell any insurance product in a jurisdiction in which such offering or sale of an insurance product is not permitted under the laws of such jurisdictions. This Subscription Agreement should be supplied in conjunction with the applicable product brochure. If you are in doubt or unsure as to the contents or implications of this agreement, you should obtain independent legal advice. Please complete in block letters and countersign any changes made. Please complete all required information. Failure to provide all relevant information may result in a delay in the processing of your Subscription Agreement. Este documento está destinado a ser puesto a disposición sólo en las jurisdicciones en que se permita la oferta o la venta de este producto de seguro, por lo tanto, no debe ser interpretado como una oferta de venta, una solicitud de compra, o una disposición de producto de seguro en cualquier otra jurisdicción. La empresa no ofrece ni comercializa los productos de seguros en una jurisdicción en la que dicha oferta o venta no esté permitida bajo las leyes de dicha jurisdicción. Este Acuerdo de Subscripción debe ser suministrado conjuntamente con el folleto del producto aplicable. Si tiene alguna duda o no está seguro sobre el contenido o las implicaciones de este acuerdo, usted debe obtener asesoramiento jurídico independiente. Por favor, complete dicho acuerdo con letra clara y corrobore cualquier cambio realizado. Por favor, complete toda la información requerida. Si no se proporciona toda la información pertinente puede resultar en un retraso en la tramitación de su Acuerdo de Subscripción. Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated Secure by A.M. Best Company. For the latest rating, access Investors Trust Assurance SPC is a member of the Association of International Life Offices (AILO). The contents are not to be reproduced or distributed to the public or press. Please consult your own legal, tax or investment professional before making any financial decisions. Investors Trust es una marca registrada de Investors Trust Assurance SPC, calificada Segura por A.M. Best Company. Para obtener la calificación más actualizada, visite Investors Trust Assurance SPC es miembro de la Association of International Life Offices (AILO). Este documento no puede ser reproducido o distribuido al público o prensa. Antes de tomar cualquier decisión financiera, consulte con un asesor profesional para obtener información sobre regulaciones legales, impuestos y/o planificación financiera. Financial Strength Rating A M BEST B++ Good Third party trademarks are used with the permission of their owners. Las marcas registradas de terceros son utilizadas con el permiso de sus dueños. Publication Date: May 2015 / Fecha de Publicación: Mayo de 2015

3 SUBSCRIPTION AGREEMENT BETWEEN / Acuerdo de Subscripción entre: 1. ITA BANK AND TRUST COMPANY LTD. of Suite 4210, 2nd Floor Canella Court, 48 Market Street, Camana Bay, PO Box 32203, Grand Cayman KY1-1208, Cayman Islands as trustee of the Investors Trust Cayman (respectively the Trustee and the Trust ) and 2. Each of the Plan Participants (as hereinafter defined). FORM IN102-2 SUBSCRIPTION AGREEMENT ACUERDO DE SUBSCRIPCIÓN A. PLAN PARTICIPANT / Participante del Plan (the First Plan Participant ); and / (el Primer Participante del Plan ); y LAST NAME or CORPORATE NAME (For corporate and other legal entities only) / Apellidos ó Nombre de la Corporación FORENAME(S) / Nombre(s) RESIDENTIAL ADDRESS / Dirección Residencial CITY / Ciudad STATE/PROVINCE / Estado/Provincia ZIP CODE / Código Postal COUNTRY / País NATIONALITY / Nacionalidad PASSPORT/ID # / Número de Pasaporte/DNI GENDER / GÉNERO MALE / MASCULI FEMALE / FEMENI RESIDENCE TELEPHONE / Teléfono Residencial Código de País Teléfono PASSPORT/ID DATE OF ISSUE / Fecha de Emisión Pasaporte PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración Pasaporte BUSINESS TELEPHONE / Teléfono Comercial Código de País Teléfono MOBILE TELEPHONE / Teléfono Celular Código de País Teléfono FAX TELEPHONE / Teléfono Fax Código de País Teléfono OCCUPATION / Ocupación / Correo Electrónico BUSINESS ADDRESS / Dirección de Negocios CITY / Ciudad STATE/PROVINCE / Estado/Provincia ZIP CODE / Código Postal COUNTRY / País B. JOINT PLAN PARTICIPANT / Co-Participante del Plan (the Joint Plan Participant ) (the First Plan Participant and the Joint Plan Participant, together, the Plan Participants ). / (el Co-Participante del Plan ) (el Primer Participante del Plan y el Co-Participante del Plan, en conjunto como los Participantes del Plan ) LAST NAME or CORPORATE NAME (For corporate and other legal entities only) / Apellidos ó Nombre de la Corporación FORENAME(S) / Nombre(s) RESIDENTIAL ADDRESS / Dirección Residencial CITY / Ciudad STATE/PROVINCE / Estado/Provincia ZIP CODE / Código Postal COUNTRY / País NATIONALITY / Nacionalidad RESIDENCE TELEPHONE / Teléfono Residencial Código de País PASSPORT/ID # / Número de Pasaporte/DNI GENDER / GÉNERO MALE / MASCULI FEMALE / FEMENI Teléfono PASSPORT/ID DATE OF ISSUE / Fecha de Emisión Pasaporte PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración Pasaporte BUSINESS TELEPHONE / Teléfono Comercial Código de País Teléfono MOBILE TELEPHONE / Teléfono Celular Código de País Teléfono FAX TELEPHONE / Teléfono Fax Código de País Teléfono OCCUPATION / Ocupación / Correo Electrónico BUSINESS ADDRESS / Dirección de Negocios CITY / Ciudad STATE/PROVINCE / Estado/Provincia ZIP CODE / Código Postal COUNTRY / País If Plan Participant(s) is/are a Corporation, please complete form IP142-1 Add/Remove Authorized Person. En caso que el/los Participante(s) del Plan fuese/fueran una Corporación, se debe completar el formulario IP142-2 Agregar/Remover Persona Autorizada. 1 Plan Participant Initials Iniciales del Participante del Plan Joint Plan Participant Initials Iniciales del Co-Participante del Plan

4 C. MINATION OF BENEFICIARIES / Designación de Beneficiarios The Plan Participants hereby designate the following as Primary and Contingent Beneficiaries: / El/Los Participante(s) del Plan por la presente designa(n) a los siguientes beneficiarios primarios y contingentes: PRIMARY BENEFICIARY / Beneficiario Principal LAST NAME / Apellido FORENAME(S) / Nombre(s) RELATIONSHIP TO PLAN PARTICIPANT / Relación con el Participante Spouse / Conyugue Child / Hijo(a) Other / Otro: PASSPORT/ID # / Nro. de Pasaporte/DNI PASSPORT/ID DATE OF ISSUE / Fecha de Emisión PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración PERCENTAGE / Porcentaje LAST NAME / Apellido FORENAME(S) / Nombre(s) RELATIONSHIP TO PLAN PARTICIPANT / Relación con el Participante Spouse / Conyugue Child / Hijo(a) Other / Otro: PASSPORT/ID # / Nro. de Pasaporte/DNI PASSPORT/ID DATE OF ISSUE / Fecha de Emisión PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración PERCENTAGE / Porcentaje CONTINGENT BENEFICIARY / Beneficiario Contingente LAST NAME / Apellido FORENAME(S) / Nombre(s) RELATIONSHIP TO PLAN PARTICIPANT / Relación con el Participante Spouse / Conyugue Child / Hijo(a) Other / Otro: PASSPORT/ID # / Nro. de Pasaporte/DNI PASSPORT/ID DATE OF ISSUE / Fecha de Emisión PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración PERCENTAGE / Porcentaje LAST NAME / Apellido FORENAME(S) / Nombre(s) RELATIONSHIP TO PLAN PARTICIPANT / Relación con el Participante Spouse / Conyugue Child / Hijo(a) Other / Otro: PASSPORT/ID # / Nro. de Pasaporte/DNI PASSPORT/ID DATE OF ISSUE / Fecha de Emisión PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración PERCENTAGE / Porcentaje D. INVESTMENT DETAILS / Detalles de Inversión The Plan Participants shall make the following investments: / El/Los Participante(s) del Plan tendrán que realizar las siguientes inversiones: PLAN CURRENCY Divisa del Plan USD $ EUR GBP REGULAR ANNUAL CONTRIBUTION AMOUNT 1 Monto Anual de Contribución Regular 1,. LUMP SUM INVESTMENT AMOUNT 2 Monto de Contribución Única 2,. PRODUCT TYPE Tipo de Producto PRODUCT TYPE Tipo de Producto EVO 10yr/años EVO 5yr/años S&P500 7 yr/años 3 Platinum Access Portfolio 5000 Series Product code / Código del Producto EVO 20yr/años EVO 15yr/años S&P500 15yr/años 3 Fixed Income 15yr - Variable Rate 3 Renta Fija 15 años - Tasa Variable 3 EVO 25yr/años Platinum Select Fixed Income 3yr - Fixed Rate 3 Renta Fija 3 años - Tasa Fija 3 Platinum Plus Fixed Income 5yr - Fixed Rate 3 Renta Fija 5 años - Tasa Fija 3 Access Portfolio 8000 Series Access Portfolio Plus Product code / Código del Producto Flex Plan 4 1. Minimum Contribution USD/EUR/GBP 1,200 annually (EVO 5 yr USD/EUR/GBP 2,400 annually ; S&P500 15yr and Fixed Income 15yr: USD 2,400 annually) / Contribución Mínima de USD/EUR/GBP anual (EVO 5 años USD/EUR/GBP anual; S&P años y Renta Fija 15 años: USD anual) 2. Minimum Contribution per product: S&P500 7 yr, Fixed Income 3yr and Fixed Income 5 yr - USD 10,000; Platinum - USD/EUR/GBP 10,000; Platinum Select USD/EUR/GBP 50,000; Platinum Plus USD/EUR/GBP 100,000; Access Portfolio products USD/EUR 75,000 (GBP 50,000); Flex Plan USD/ EUR/GBP 100. / Contribución Mínima por producto: S&P500 7 años, Fixed Income 3 años y Fixed Income 5 años- USD ; Platinum - USD/EUR/GBP ; Platinum Select USD/EUR/GBP ; Platinum Plus USD/EUR/GBP ; Productos de Access Portfolio USD/EUR (GBP ); Plan Flex USD/EUR/GBP USD Only / USD únicamente. 4. This product is only available for existing Plan Participants with inforce or paid up policies, or Introducers. / Este producto está disponible únicamente para clientes existentes con pólizas pagadas o vigentes, e Introductores activos. E. THE PLAN PARTICIPANTS CHOICE OF INVESTMENT FUND(S) AND THE INVESTMENT IN EACH ARE SPECIFIED BELOW. 5 / Por favor indicar los Fondos seleccionados y sus Porcentajes Respectivos de Inversión. 5 FUND CODE CÓDIGO DEL FONDO FUND NAME MBRE DEL FONDO Min. $/ / 120 per fund Min. $/ / 120 por fondo 5. a. For all Evolution and Platinum products, if no investment fund is specified or if any of the specified funds are unavailable, the Company will allocate the contributions into a cash equivalent fund. b. For all S&P 500 products, the Company will allocate the contributions to a structured note product with relative returns linked to the performance of index S&P 500. No choice of investment fund(s) is necessary. c. For all Fixed Income products, the Company will allocate the contributions to a USD fund portfolio with fixed competitive interest rate. No choice of investment fund(s) is necessary. d. For all Access Portfolio products, contributions will be allocated into cash. No choice of investment fund(s) is necessary. e. For all Flex Plan products, contributions will be allocated into a cash equivalent fund. No choice of investment fund(s) is necessary. / 5. a. Para todos los productos Evolution y Platinum, si no se especifica ningún fondo de inversión o si alguno de los fondos especificados no están disponibles, la Compañía le asignará las contribuciones a un fondo equivalente a efectivo. b. Para todas los productos S&P 500, la Compañía destinará las contribuciones a notas estructuradas con retornos relativos vinculados al rendimiento del índice S&P 500. c. Para todos los productos de Renta Fija, la Compañía destinará las contribuciones a una cartera de fondos en USD con tasa fija de interés competitiva. d. Para todos los productos Access Portfolio, las contribuciones se asignarán a dinero en efectivo. e. Para todos los productos Flex, las contribuciones se destinarán a un fondo equivalente a efectivo. 2 Plan Participant Initials Iniciales del Participante del Plan Joint Plan Participant Initials Iniciales del Co-Participante del Plan

5 F. CONTRIBUTION METHOD AND INSTRUCTIONS / Métodos e Instrucciones de Pago CREDIT CARD / TARJETA DE CRÉDITO Major Credit Cards are accepted. Se aceptan las principales tarjetas de crédito. CHECK / CHEQUE Only checks drawn from US registered Bank Accounts are accepted. Please make check payable to Investors Trust. Se aceptan cheques pagaderos sobre cuentas de bancos de EE.UU. Los cheques deben ser pagaderos a Investors Trust. WIRE TRANSFER / TRANSFERENCIA BANCARIA International Wire Transfers are accepted. Se aceptan transferencias bancarias internacionales. DIRECT DEBIT / DÉBITO DIRECTO Direct debit from US bank accounts are limited to amounts below USD 100,000. Se aceptan débitos directos de cuentas de bancos de EE.UU. por cantidades menores a USD To provide the instructions of your selected contribution method please complete and attach the Payment Authorization Form (IP114-1). Para proveer instrucciones completas de su método de pago seleccionado por favor adjunte el formulario de Autorización de Pago (IP114-2). G. ADDITIONAL INFORMATION / Información Adicional Are any of the Plan Participants and/or Payors, currently or have been in the past, one of the following / Por favor indique si alguno de los Participantes del Plan y/o Pagadores se identifica en la actualidad o en el pasado con algunas de las siguientes opciones: A senior military, governmental, or political official in a non-us country? If yes, please complete form IG132-2 Source of Funds Questionnaire Un militar de alto rango, funcionario gubernamental o político de un país distinto a los EE.UU.? Si es así, por favor complete el formulario IG132-2 Cuestionario de Procedencia de los Fondos Closely associated with or an immediate family member of such official? If yes, please complete form IG132-2 Source of Funds Questionnaire Un pariente cercano o una persona estrechamente asociada con un funcionario con las características descritas en la opción anterior? Si es así, por favor complete el formulario IG132-2 Cuestionario de Procedencia de los Fondos None of the above Ninguna de las opciones anteriores H. PREFERRED LANGUAGE FOR COMMUNICATIONS / Idioma de preferencia para comunicaciones ENGLISH INGLÉS SPANISH ESPAÑOL PORTUGUESE PORTUGUÉS CHINESE TRADITIONAL CHI TRADICIONAL CHINESE SIMPLIFIED CHI SIMPLIFICADO JAPANESE JAPONÉS RUSSIAN RUSO I. MAILING ADDRESS / Dirección para Correspondencia This address will be used if the Company needs to physically mail the Plan Participant(s) any Plan related documents. / Esta dirección se utilizará si la Compañía necesitara enviar al/los Participante(s) del Plan documentos físicos relacionados al Plan de Inversión. (select only one option / seleccione una opción únicamente) FIRST PLAN PARTICIANT - Residential Address PRIMER PARTICIPANTE DEL PLAN - Dirección Residencial JOINT PLAN PARTICIPANT - Residential Address CO-PARTICIPANTE DEL PLAN - Dirección Residencial FIRST PLAN PARTICIANT - Business Address PRIMER PARTICIPANTE DEL PLAN - Dirección de Negocios JOINT PLAN PARTICIPANT - Business Address CO-PARTICIPANTE DEL PLAN - Dirección de Negocios J. ISSUED POLICY TYPE / DELIVERY METHOD Tipo de Póliza a Emitir / Método de Entrega (select only one option / seleccione una opción únicamente) E-POLICY PÓLIZA ELECTRÓNICA Commitment to Green Select electronic delivery of the policy documents and receive a USD/EUR 25 (GBP 15) rebate as a reward for supporting our Green initiative! Opte por recibir los documentos de la póliza electrónicamente y reciba una bonificación de USD/EUR 25 (GBP 15) como recompensa por apoyar nuestra iniciativa ecológica! PRINTED POLICY DELIVERED TO MY INTRODUCER 6 PÓLIZA IMPRESA PARA SER ENVIADA A MI INTRODUCTOR 6 PRINTED POLICY DELIVERED TO THE SELECTED MAILING ADDRESS 6 PÓLIZA IMPRESA PARA SER ENVIADA A LA DIRECCIÓN PARA CORRESPONDENCIA SELECCIONADA Delivery of printed policies is not available in all countries, verify with the Company before submitting the Subscription Agreement. If the selected delivery method is not available in your country, the Company will send an electronic policy (e-policy) instead. La entrega de las pólizas impresas no se encuentra disponible en todos los países, verifique con la Compañía antes de presentar el Acuerdo de Suscripción. Si el método de entrega seleccionado no está disponible en su país, la Compañía enviará una póliza electrónica (e-policy). K. EXISTING POLICIES / Pólizas Existentes Please provide details of any existing Investors Trust s policies you have or are making payments to (if applicable) / Por favor, proporcione los detalles de todas las pólizas de Investors Trust que usted tenga o en las cuales realice pagos (si aplica) PRODUCT TYPE Tipo de Producto POLICY NUMBER Número de Póliza PRODUCT TYPE Tipo de Producto POLICY NUMBER Número de Póliza 3 Plan Participant Initials Iniciales del Participante del Plan Joint Plan Participant Initials Iniciales del Co-Participante del Plan

6 L. DECLARATION / Declaración by the Plan Participants to the Trustee: Each Plan Participant jointly and severally: (1) represents that the information provided by the Plan Participants in this Subscription Agreement is accurate and complete; (2) acknowledges that a copy of the Declaration of Trust relating to the Investors Trust Cayman dated November 21, 2011 (the Declaration of Trust ) has been provided to them; (3) desires and hereby requests the Trustee to constitute a Sub-fund for the benefit of the Beneficiaries; (4) directs the Trustee to invest funds contributed by the Plan Participants in a Policy issued by the Insurance Company allocated to such Sub-fund; (5) represents and acknowledges that each Plan Participant has read carefully this Subscription Agreement, the Declaration of Trust and the form of Policy to be entered into between the Trustee and the Insurance Company; (6) represents, acknowledges, and agrees that the Plan Participants have full responsibility for the selection and choice of Investment Plans; (7) represents and acknowledges that each of them has seen and signed the Plan Illustration or any substitute document as established by the Company, attached to this Subscription Agreement; (8) represents and warrants that it is not: a. a citizen or resident of the United States of America; b. or a corporation or other entity deemed situated in the United States of America under the tax laws and Regulations (as defined in the Declaration of Trust) of the United States of America; or c. physically present in the United States of America for a number of days in a taxable year which would result in it being taxable as a resident alien under the substantial presence test of Section 7701(b) of the Code; or d. a member of the public In the Cayman Islands. Each Plan Participant hereby represents, warrants, and agrees that: i. it is aware that any failure to comply with the foregoing may result in material adverse tax consequences and that the Trustee shall have no liability therefor; and ii. it will immediately advise the Trustee should there be any failure to comply with the foregoing; (9) represents, acknowledges and agrees that the Plan Participants have not and will not contribute to the Trust any criminal property (as that term is defined in the Proceeds of Crime Law, 2008 of the Cayman Islands); (10) represents, acknowledges, and agrees that all funds must be sent directly to the Trustee either by check, wire or credit card payment and that any funds given to any intermediary will be at the sole risk of the Plan Participants. WHEREAS The Trustee has established the Investors Trust Cayman trust under the Trusts Law (as revised) of the Cayman Islands; A separate sub-fund shall be constituted under the Trust herein (the Sub-fund ); Under the terms of the Trust, using one or more Sub-funds the Trustee shall purchase one or more insurance policies from the Investors Trust Segregated Portfolio of Investors Trust Assurance SPC (respectively the Policies, the Segregated Portfolio and the Insurance Company ) with monies received from Plan Participants (the Plan ); The Trustee shall direct the Insurance Company to invest the premium payments paid from the Sub-fund in investment funds specified by the Plan Participants (the Investment Plans ); The Trustee shall administer the Plan in accordance with the terms of the Trust and this Subscription Agreement 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 Participants in this Subscription Agreement. W IT IS HEREBY AGREED AS FOLLOWS 1. DEFINITIONS In addition to terms otherwise defined herein, where the context so admits the following expression shall have the following respective meanings: Beneficiaries means the Primary Beneficiaries and Contingent Beneficiaries designated in the Nomination of Beneficiaries Section of this Subscription Agreement as beneficiaries and as applicable the estate of the Insured designated in Section 6 of this Subscription Agreement as beneficiary. Code means the Internal Revenue Code of Insurance Company means Investors Trust Assurance SPC on behalf of Investors Trust Segregated Portfolio, or another insurance company (or segregated portfolio thereof) selected. Insured means the Plan Participant(s) (unless otherwise specified in this Subscription Agreement) as the person(s) whose life is insured under each Policy. Investment Plans means the investment funds, specified by the Plan Participants in or pursuant to this Subscription Agreement, in which the Trustee shall direct the Insurance Company to invest funds contributed by the Plan Participants. Plan means the arrangement whereby the Trustee makes payments related to one or more Policies for the benefit of one or more of the Beneficiaries with monies received from the Plan Participants. Policies means insurance policies, supplemental to a master insurance policy, which insures the life of the Insured that are purchased from the Insurance Company in accordance with the terms of the Plan. Time of Maturity means the date on which the Policies mature. Trust means the trust declared by the Trustee for the Plan, currently known as the Investors Trust Cayman. Trustee means the trustee or trustees holding office under the Trust from time to time. OTHER INTERPRETATION (a) the singular shall include the plural and vice versa; (b) the masculine gender shall include the feminine gender and vice versa; (c) the neuter gender shall include the masculine and feminine and vice versa; (d) persons shall include companies, corporations, organizations, partnerships and other legal entities; (e) headings shall not be construed as part of this document; (f) this Subscription Agreement shall be construed in tandem with the provisions of the Trust Deed but to the extent that any provisions hereof are inconsistent therewith, the terms of the Trust Deed shall prevail; (g) capitalized terms used but not otherwise defined in this Subscription Agreement have the meanings assigned thereto in the Trust Deed. 2. FRAUDULENT DISPOSITIONS Each Plan Participant warrants that no transfer of money or other property by them to the Trustee will at the time made constitute a fraudulent disposition under applicable law, i.e. that each such transfer has not been made at an undervalue and has not been made with an intention to defraud a creditor of the Plan Participants. 3. THE TRUST INSTRUMENT Each Plan Participant agrees that it shall be subject to and bound by all of the provisions of the Declaration of Trust and this Subscription Agreement. Without limiting the generality of the foregoing, each Plan Participant acknowledges and agrees: that funds contributed by the Plan Participants will be credited to a Sub-fund and used to purchase one or more Policies for the benefit of one or more of the Beneficiaries; that the making of such contribution constitutes each Plan Participant s agreement to the terms of the Declaration of Trust and this Subscription Agreement and such Plan Participant s agreement to be bound thereby. 4. PURCHASE OF THE INVESTMENT PLANS With funds received from the Plan Participants, the Trustee shall purchase one or more Policies and shall continue to pay the premiums due thereon so long as funds contributed by the Plan Participants are available in the Sub-fund. 4 Plan Participant Initials Iniciales del Participante del Plan Joint Plan Participant Initials Iniciales del Co-Participante del Plan

7 L. DECLARATION (continued) / Declaración (continuación) 5. PAYMENTS TO THE TRUST The Plan Participants have opted for a method of payment to the Trustee, as shown in this Subscription Agreement, and such method may be changed by the Plan Participants, if agreed to by the Trustee, after written notice requesting a change has been given by the Plan Participants to the Trustee. 6. THE BENEFICIARIES The names of those who are to be Beneficiaries are (subject to the last sentence of this Section) as listed in the above Nomination of Beneficiaries section of this Subscription Agreement are subject to compliance with applicable law (including laws and regulations directed at the prevention of money laundering) at any time, and from time to time. Upon receipt by the Trustee of a written notice signed by all the Plan Participants, Beneficiaries may be deleted or added or the order or proportion of their potential benefit may be changed. If there are surviving Primary Beneficiaries at the time of a distribution from the Subfund, payment of such funds shall be made to the surviving Primary Beneficiaries in proportion to the percentage entitlements of such Primary Beneficiaries as set out in this Subscription Agreement (such that if there is only one surviving Primary Beneficiary such surviving Primary Beneficiary shall receive all such funds). If there are no surviving Primary Beneficiaries at the time of a distribution from the Sub-fund, payment of such funds shall be made by the Trustee to each Contingent Beneficiary in proportion to the percentage entitlements of such Contingent Beneficiary as set out in this Subscription Agreement (such that if there is only one surviving Contingent Beneficiary such surviving Contingent Beneficiary shall receive all such funds). If there are no surviving Primary Beneficiaries or Contingent Beneficiaries at the time of the distribution of funds from the Sub-fund, payment of such funds shall be made by the Trustee to the estate of the Insured. 7. DEFAULT IN CONTRIBUTION PAYMENTS If the Plan Participants fail to make the necessary scheduled contribution, the Trustee shall not be under any obligation to make any payment on any Policy if funds are not available within the Sub-fund for such purpose. Therefore in the absence of due Policy premium payments within the Policy s pre-established grace period and subject to the discretion of the Insurance Company, the Policy may be lapsed and as permitted by applicable law funds (if any) may be requested by the Plan Participants, in accordance with the Policy s Surrender Provisions. 8. INVESTMENT SELECTIONS To the extent that any Policy enables a choice of investments for a Sub-fund, the Trustee shall instruct that such investments be made in accordance with the directions of the Plan Participants as set forth in this Subscription Agreement. Changes in investment selection may be made at any time and from time to time by all the Plan Participants as permitted by the Insurance Company, the Investment Plans and the Trustee. 10. CONFIRMATION OF REPRESENTATIONS AND WARRANTIES / INDEMNITY Each Plan Participant hereby confirms the accuracy of all information and the validity of all representations and warranties provided to the Trustee in connection with the Plan and/or the subscription for Investment Plans and for the Policy, howsoever provided, including the terms of this Subscription Agreement and the contents of any personal or medical questionnaire (together Representations & Warranties ). Each Plan Participant acknowledges that certain of such information will be provided to the Insurance Company on behalf of the Segregated Portfolio as the issuer of the Policy and potentially to reinsurers thereof, and that any inaccuracy therein may result in the invalidity of such Policy or the investments in the related Investment Plans and the loss of all funds contributed or paid in relation thereto. Each Plan Participant hereby undertakes to inform the Trustee of any change in any matter that forms the subject of any of the Representations & Warranties. Each Plan Participant hereby undertakes to indemnify, defend, and hold harmless the Trustee against any loss or damage (including, without limitation, attorney s fees) occasioned by any inaccuracy in any of the Representations & Warranties or failure to advise the Trustee of any change in any matter that forms the subject of any of the Representation & Warranties. Each Plan Participant agrees that the Trustee shall be entitled to rely on and to act in accordance with any written instruction purported to be provided by a Plan Participant and each Plan Participant hereby undertakes to indemnify, defend, and hold harmless the Trustee against any loss or damage (including, without limitation, attorney s fees) occasioned by the Trustee acting in accordance with any such instruction. 11. PAYMENT OF BENEFITS The Trustee shall ensure that payments are made to the Beneficiaries in respect of proceeds received from the Insurance Company upon the death of the insured under a Policy, in accordance with the Policy s Death Benefit Provisions. 12. FEES AND EXPENSES The Trustee, Administrator (if any exists) and Insurance Company shall charge its fees and expenses as provided in the Trust Deed and Policy. 13. VERIFICATION OF IDENTIFICATION AND SOURCE OF FUNDS As part of the Trust s responsibility for the prevention of money laundering, and in regard to other matters, the Trustee will require detailed verification of each Plan Participant and Beneficiary s identity and the source of the subscription funds. 14. INDEMNITY AND PROTECTIONS The Trustee and other Indemnified Parties (each as such and in its individual capacity) are provided with comprehensive indemnity and other protections in the Trust Deed as described in the Trust Deed. 9. REVOCATION The Plan Participants may give notice of revocation of that portion of the Trust as constituted by the Sub-fund to the Trustee at any time, in which case the Trustee will surrender to the Insurance Company each Policy allocated to the Sub-fund established in relation to the Plan Participants, and upon receipt by the Trustee of any funds from the Insurance Company in relation to such Policies shall distribute the net proceeds to the Plan Participants. The payment, and timing of payments to the Plan Participants following a revocation, will depend upon the redemption value of each, the receipt of funds in respect thereof from the Insurance Company and compliance with applicable law. 15. GOVERNING LAW This agreement is created under and shall be governed by and construed and enforced in accordance with the laws of the Cayman Islands (without regard to conflict of laws principles), which may include the requirement to report certain personal information to other jurisdictions. 16. SUBJECT TO ACCEPTANCE This Subscription Agreement (which in its entirety consists of pages 1 through 5 hereof) is subject to acceptance by the Trustee and will not be effective unless and until accepted by the Trustee. Such acceptance of this Subscription Agreement by the Trustee shall be evidenced exclusively by the Trustee s countersignature of this Subscription Agreement. IN WITNESS WHEREOF THIS SUBSCRIPTION AGREEMENT HAS BEEN EXECUTED AND DELIVERED AS A DEED by each Plan Participant on the day of, 20 (EN FE DE LO CUAL ESTE ACUERDO DE SUSCRIPCIÓN SE HA EJECUTADO Y ENTREGADO COMO UN CONTRATO por cada participante del plan a partir del) PRINT NAME HERE THE FIRST PLAN PARTICIPANT / Nombre del Primer Participante del Plan PRINT NAME HERE JOINT PLAN PARTICIPANT / Nombre del Co-Participante del Plan Signed by / Firmado por, Signed by / Firmado por, 5

8 M. INDEPENDENT INTRODUCER DETAILS / Detalles del Introductor Independiente DECLARATION OF INDEPENDENT INTRODUCER / Declaración de Introductor Independiente 1. I certify that I was introduced to the Plan Participant(s) on the following date: Certifico que conozco a el/los Participantes(s) del Plan desde la siguiente fecha: Year and Month / Año y Mes 2. I certify that I have seen and verified the contents of the original identification documents provided with this Subscription Agreement. Certifico que yo he visto y verificado los documentos de identificación originales provistos en este Acuerdo de Subscripción. 3. I confirm that I have explained to the Plan Participant(s) the requirements and the need for completing, the Source of Funds, the Medical Questionnaire and the Declaration (together, the Associated Documents ). Confirmo que le he explicado a el/los titulares de la póliza los requisitos y la necesidad de completar el Cuestionario de Origen de los Fondos, el Cuestionario Médico y la Declaración (juntos, los Documentos Asociados ). 4. I also confirm that I have taken reasonable steps to ensure that the funding is legitimate, and where sourced from the Plan Participant s earnings is in line with the proposed Plan Participant s income. Confirmo que he tomado las medidas necesarias para asegurar que los fondos utilizados en este Acuerdo de Subscripción sean legítimos, y que cuando provienen de los ingresos de el/los Participante(s) del Plan estén de acuerdo con sus ingresos. 5. I declare that to the best of my knowledge, all the information provided with this Subscription Agreement is true and complete and that I will provide further information if required. Declaro que hasta donde llega mi conocimiento toda la información proporcionada en este Acuerdo de Subscripción es verdadera y completa, y que proporcionaré más información en caso de ser requerido. 6. I enclose the Subscription Agreement and the related documents (including the Associated Documents) duly completed in original or certified form, and confirm that the signature(s) contained in the Subscription Agreement and the related documents are signed by the Persons they purport to be. Envío el Acuerdo de Subscripción y los documentos relacionados (incluyendo los Documentos Asociados) debidamente completados en original o certificados, y confirmo que la(s) firma(s) contenida(s) en este Acuerdo de Subscripción y en los documentos relacionados fueron firmados por las personas indicadas. 7. This Subscription Agreement was executed by the Plan Participant(s) in my presence. Este Acuerdo de Subscripción fue ejecutado por el/los Participante(s) del Plan en mi presencia. PRINT NAME OF INTRODUCER / MBRE DEL INTRODUCTOR INTRODUCER CODE / CÓDIGO DEL INTRODUCTOR SIGNATURE OF INTRODUCER / FIRMA DEL INTRODUCTOR DATE / FECHA 6

9 1 PLAN PARTICIPANT INFORMATION / INFORMACIÓN DEL PARTICIPANTE DEL PLAN PLAN PARTICIPANT S NAME MBRE DEL PARTICIPANTE DEL PLAN JOINT PLAN PARTICIPANT S NAME MBRE DEL CO-PARTICIPANTE DEL PLAN FORM IP142-2 ADD/REMOVE AUTHORIZED PERSON AGREGAR/REMOVER PERSONA AUTORIZADA DATE FECHA POLICY NUMBER NÚMERO DE PÓLIZA ADD NEW AUTHORIZED PERSON / AGREGAR NUEVA PERSONA AUTORIZADA 2 Important Notice / Aviso Importante The Plan Participant(s) hereby understand(s) and agree(s) that / El participante del plan por la presente entiende y está de acuerdo con: 1. The Authorized Person will have the authority to approve and sign any request related to the Policy, either online or in paper. / La persona autorizada tendrá autoridad para aprobar y firmar cualquier petición relacionada con la póliza, ya sea en el sitio web o mediante formularios. 2. The Authorized Person is bound to the Plan Participant(s); therefore, the Authorized Person will have access and authority to all Policies, Accounts, Loans and Contracts the Plan Participant(s) may have with Investors Trust Assurance SPC. / La persona autorizada está vinculada al participante del plan, por lo tanto la persona autorizada tendrá acceso y permiso a todas las pólizas, cuentas, préstamos y contratos que el participante del plan pueda tener con Investors Trust Assurance SPC. RELATIONSHIP TO PLAN PARTICIPANT RELACIÓN CON EL PARTICIPANTE DEL PLAN LAST NAME / Apellido FIRST NAME / Primer Nombre MIDDLE NAME / Segundo Nombre COUNTRY OF NATIONALITY / País de Nacionalidad GENDER / Género MALE Masculino PASSPORT / ID # / No. de Pasaporte FEMALE Femenino TYPE OF ADDRESS / Tipo de Dirección BUSINESS RESIDENTIAL Comercial Residencial ADDRESS / Dirección PASSPORT/ID DATE OF ISSUE / Fecha de Emisión PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración CITY / Ciudad STATE OR PROVINCE / Estado o Provincia ZIP CODE / Codigo postal COUNTRY / País MOBILE TELEPHONE / Teléfono Móvil FAX TELEPHONE / Teléfono Fax HOME TELEPHONE / Teléfono de Residencia BUSINESS TELEPHONE / Teléfono Comercial / Correo Electrónico OCCUPATION / Ocupación Required Supporting Documents: A clear copy of a valid Identification Document (ex: passport, government ID, etc.) and Proof of Address (ex: Utility Bill, Bank Statement, etc.) for the Authorized Person no more than 3 months old. If the Authorized Person is not a director please provide documents proving the relation between the Authorized Person and the organization (ex: Power of Attorney, Board of Directors Appointment, etc.) / Documentos de soporte requeridos: Una copia legible de un Documento de Identificación válido que contenga la firma de la persona (ej. Pasaporte, Documento de Identidad Gubernamental, etc.) y Prueba de Residencia (ej. Factura de Servicios, Estado de Cuenta bancario, etc.) No mayor a los 3 meses de antiguedad. The Authorized Person will be able to review and manage business information online in ITA s secure Account Access Website. To set-up an online web user account to access this website / La Persona Autorizada podrá revisar y administrar toda la información comercial en la página de Acceso Privado de Investors Trust. Para poder configurar un usuario en línea y acceder a este sitio web, existen dos opciones: The Authorized Person will personally register and set-up his/her Web User online. / La Persona Autorizada deberá el mismo registrarse y configurar en línea su usuario. The Introducer requests ITA to set his/her Authorized Person s User ID to be / El Introductor solicita a ITA que establezca un usuario para la Persona Autorizada a ser: REMOVE AUTHORIZED PERSON / REMOVER PERSONA AUTORIZADA 3 Indicate the name of the Authorized person to be removed / Indicar el nombre de la Persona Autorizada que será removida LAST NAME / Apellido FIRST NAME / Primer Nombre MIDDLE NAME / Segundo Nombre SIGNATURE(S) / FIRMA(S) 4 PLAN PARTICIPANT S SIGNATURE FIRMA DEL PARTICIPANTE DEL PLAN JOINT PLAN PARTICIPANT S SIGNATURE FIRMA DEL C0-PARTICIPANTE DEL PLAN NEW AUTHORIZED PERSON S SIGNATURE FIRMA DE LA NUEVA PERSONA AUTORIZADA INTRODUCER S SIGNATURE FIRMA DEL INTRODUCTOR INTRODUCER CODE CÓDIGO DEL INTRODUCTOR Copyright 2015 Investors Trust Assurance SPC Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated Secure by A.M. Best Company. For the latest rating, access Investors Trust Assurance SPC is a member of The Association of International Life Offices (AILO). For more information, please visit: If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands. LA TRADUCCIÓN DE ESTE DOCUMENTO A OTRO IDIOMA DISTINTO AL INGLES, TIENE EL ÚNICO PROPÓSITO DE FACILITAR LA COMPRENSIÓN DE DICHO DOCUMENTO A INDIVIDUOS QUE TIENE COCIMIENTO DEL IDIOMA INGLES. NUESTRA INTENCIÓN ES DE PROVEER LA TRADUCCIÓN MAS PRECISA POSIBLE DEL DOCUMENTO ORIGINAL EN INGLES, PERO DADO A DIFICULTADOS DE INTERPRETACIÓN, PUEDEN EXISTIR PEQUEÑAS DISCREPANCIAS DE LENGUAJE. ASUMIMOS RESPONSABILIDAD POR LA PRECISIÓN DE LA TRASCRIPCIÓN, Y DECLINAMOS LA OBLIGACIÓN ANTE CUALQUIER RECLAMO. add/remove authorized person Version 05/2015

10 PLAN PARTICIPANT INFORMATION / INFORMACIÓN DEL PARTICIPANTE DEL PLAN PLAN PARTICIPANT S NAME MBRE DEL PARTICIPANTE DEL PLAN 1 JOINT PLAN PARTICIPANT S NAME MBRE DEL CO-PARTICIPANTE DEL PLAN FORM IG132-2 SOURCE OF FUNDS QUESTIONNAIRE Cuestionario de Origen de los Fondos To be completed by ALL cases with a Premium of USD$ / EUR / GBP 10,000 or above. Questionnaire will be valid for a period of 3 years only. After that period, a new questionnaire will be required. Para ser completado en TODOS los casos de Contribuciones de USD$ / EURO / GBP o mayor. El cuestionario será valido únicamente por un período de 3 años. Al finalizar ese período, se requerirá un nuevo cuestionario. DATE FECHA POLICY NUMBER NÚMERO DE PÓLIZA QUESTIONNAIRE / CUESTIONARIO THIS QUESTIONNAIRE IS BEING COMPLETED FOR / ESTE CUESTIONARIO ESTÁ SIENDO COMPLETADO PARA: 2 FIRST PLAN PARTICIPANT / PRIMER PARTICIPANTE DEL PLAN JOINT PLAN PARTICIPANT / CO-PARTICIPANTE DEL PLAN PAYOR (if other than the Plan Participant(s)) PAGADOR (en caso que no sea el Participante del Plan) PAYOR S NAME / MBRE DEL PAGADOR: Please note that the company requires one Source of Fund Questionnaire per Plan Participant and one for each Payor, if other than Plan Participant(s). Therefore, additional forms should be submitted for each person when applicable. Tenga en cuenta que la empresa requiere un Cuestionario de Origen de Fondos por cada uno de los Participante del Plan y uno por cada Pagador (en caso que fuese diferente al Participante del Plan). Por lo tanto, formularios adicionales deberán ser enviados para cada persona en caso que fuese necesario. A) Please indicate annual income of the person or entity completing this questionnaire / Por favor indique el salario/ingreso anual de la persona o entidad completando este cuestionario: Below USD 25,000 / Menor de USD USD 50,000 to USD 100,000 / USD a USD USD 250,000 to USD 500,000 / USD a USD USD 25,000 to USD 50,000 / USD a USD USD 100,000 to USD 250,000 / USD a USD USD 500,000 and above / Mayor de USD B) If this questionnaire is being completed for a corporation, who are the current directors and shareholders, and do any holding companies and subsidiaries exist? / Si este cuestionario está siendo completado por una corporación, por favor indicar quienes son los directores y accionistas actuales, y si existe alguna compañía controladora o subsidiaria. C) If this questionnaire is being completed for a trust, please advise the identity of the parties / Si este cuestionario está siendo completado para un Fideicomiso (Trust), por favor indicar la identidad de las partes: D) Is the person or entity completing this questionnaire, currently or has been in the past, one of the following: (A) A senior military, governmental, or political official in a non-us country, or (B) Closely associated with or an immediate family member of such official? / Indique si la persona o entidad completando este cuestionario es actualmente o fue: (A) un militar de alto rango, funcionario gubernamental o político de un país distinto a los EE.UU., ó (B) está estrechamente asociada con un funcionario de dichas características o es un miembro de su familia inmediata? If Yes, please provide details: / Si respondió afirmativamente, favor proveer detalles a continuación: YES / SI E) Bank information of the person or entity completing this questionnaire / Información Bancaria de la persona o compañía completando este cuestionario: NAME OF BANK / Nombre del Banco: ACCOUNT NUMBER / Número de Cuenta: BANK S ADDRESS / Dirección: DATE OPENED / Fecha de Apertura: F) Please indicate how the funds have been obtained for this investment: / Por favor indicar cómo se obtuvieron los fondos para esta inversión: SALE OF PROPERTY OR OTHER ASSETS VENTA DE PROPIEDADES U OTROS ACTIVOS CURRENT INCOME INGRESO/ SALARIO INVESTMENT GAIN / LOAN / SAVING GANANCIA PROVENIENTE DE INVERSIÓN / PRÉSTAMO / AHORROS COMPENSATION PAYMENT / MATURING INVESTMENT / POLICY CLAIM PAGO COMPENSATORIO / MADURACIÓN DE INVERSIÓN / RECLAMO DE PÓLIZA INHERITANCE HERENCIA WINNINGS PREMIO GIFT REGALO Please provide details and required documentation for any boxes checked above / Por favor proveer detalles sobre las respuestas seleccionadas arriba: G) Is the person or entity completing this questionnaire either: (A) a U.S. citizen and/or resident for tax reporting purposes, or (B) a UK resident for tax reporting purposes? Es la persona completando este cuestionario: (A) un ciudadano y/o residente de los EE.UU. para efectos fiscales, ó (B) un residente del Reino Unido para efectos fiscales? If Yes, please provide the appropriate information below: / Si respondió afirmativamente, favor proveer la información apropiada a continuación: A) U.S. Tax Identification Number Número de Identificación Fiscal de los EE.UU. B) UK National Insurance Number Número del Seguro Nacional del Reino Unido YES / SI H) What is the purpose of this investment, (Retirement, education, etc.): / Cuál es el propósito de esta inversión, (retiro, educación, etc)? Por favor indicar: I) Have the address(es) of the person or entity completing this questionnaire changed during the past three years, or since the inception of policy, whichever is greater? (existing Policies only) La persona o entidad que completa este cuestionario ha cambiado la dirección durante los últimos tres años o desde el inicio de la póliza? (para Pólizas existentes únicamente) YES / SI If Yes, please complete and provide form IP100-1 Customer Service Request to note any change of address. / Si respondió afirmativamente, por favor complete y envíe el formulario IP100-2 Solicitud de Servicio al Cliente para cualquier cambio de dirección. DECLARATION / DECLARACIÓN I/We, the undersigned, as Plan Participants(s) and the Payor, if other than Plan Participant(s), hereby certify that all the information I provided N V E S T Oabove R S Tis Rtrue U S Tand correct. 3 4 Yo/Nosotros, el/los suscrito(s), como Participante(s) del Plan y Pagador (en caso que fuese diferente al Participante del Plan) declaro(amos) que toda la información provista anteriormente es verdadera y correcta. PAYOR S SIGNATURE (if other than Plan Participant(s)) / FIRMA DEL PAGADOR (en caso que fuese diferente al Participante del Plan) SIGNATURE / FIRMA SIGNATURE(S) / FIRMA(S) PLAN PARTICIPANT S SIGNATURE FIRMA DEL PARTICIPANTE DEL PLAN 5 JOINT PLAN PARTICIPANT S SIGNATURE FIRMA DEL CO-PARTICIPANTE DEL PLAN INTRODUCER S SIGNATURE FIRMA DEL INTRODUCTOR INTRODUCER CODE CÓDIGO DEL INTRODUCTOR Copyright 2015 Investors Trust Assurance SPC Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated Secure by A.M. Best Company. For the latest rating, access Investors Trust Assurance SPC is a member of The Association of International Life Offices (AILO). For more information, please visit: If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands. source of funds questionnaire Version 05/2014

11 FORM IN110-2 INSURED PERSON / ASEGURADO(A) PLEASE COMPLETE ONE FORM PER INSURED PERSON POR FAVOR COMPLETE UN FORMULARIO POR CADA PERSONA ASEGURADA PLAN PARTICIPANT INFORMATION / INFORMACIÓN DEL PARTICIPANTE DEL PLAN PLAN PARTICIPANT S NAME 1 MBRE DEL PARTICIPANTE DEL PLAN JOINT PLAN PARTICIPANT S NAME MBRE DEL CO-PARTICIPANTE DEL PLAN DATE FECHA POLICY NUMBER NÚMERO DE PÓLIZA De forma predeterminada, si la Póliza tiene un solo Participante del Plan, él o ella será el/la único(a) Asegurado(a) en la Póliza. Si la Póliza tiene dos Participantes del Plan, ambos titulares serán los Asegurados en la Póliza. Sin embargo, el/los Participante(s) del Plan puede(n) nombrar a una persona que no sea a sí mismos como el Asegurado. Si hay más de un Asegurado indicado en las Páginas de Datos de la Póliza, el Beneficio por Defunción será pagado únicamente luego del deceso del último Asegurado sobreviviente y solo un Beneficio por Defunción deberá ser pagado. La compañía requiere que cada uno de los Asegurados completen el formulario IN110, por lo tanto, un formulario adicional deberá ser presentado si existiese un segundo Asegurado en la Póliza. INSURED PERSON (select only one) / ASEGURADO(A) (seleccione sólo uno) 2 PARTICIPANTE DEL PLAN CO-PARTICIPANTE DEL PLAN DESIGNE A UNA NUEVA PERSONA COMO ASEGURADO(A) (Por favor complete la sección 2b de esta solicitud) ADD NEW INSURED PERSON (if applicable) / AGREGAR UNA NUEVA PERSONA COMO ASEGURADO (si aplica) Insured Person Information / Información del Asegurado 2b LAST NAME / Apellido FIRST NAME / Primer Nombre MIDDLE NAME / Segundo Nombre COUNTRY OF NATIONALITY / País de Nacionalidad CITY / Ciudad GENDER / Género MALE FEMALE Masculino Femenino PASSPORT / ID # / No. de Pasaporte TYPE OF ADDRESS BUSINESS RESIDENTIAL Comercial Residencial STATE OR PROVINCE / Estado o Provincia PASSPORT/ID DATE OF ISSUE / Fecha de Emisión ADDRESS / Dirección ZIP CODE / Código Postal COUNTRY / País PASSPORT/ID DATE OF EXPIRY / Fecha de Expiración MOBILE TELEPHONE / Teléfono Móvil FAX TELEPHONE / Teléfono Fax HOME TELEPHONE / Teléfono de Residencia BUSINESS TELEPHONE / Teléfono Comercial / Correo Electrónico OCCUPATION / Ocupación Documentos de soporte requeridos por parte de la persona asegurada: una copia legible de un Documento de Identificación válido que contenga la firma de la persona (ej. Pasaporte, Documento de Identidad Gubernamental, etc.) y una Prueba de Residencia (ej. Factura de Servicios, Estado de Cuenta bancario, etc.) que no tenga más de 3 meses de antigüedad. MEDICAL QUESTIONNAIRE FOR INSURED PERSON / CUESTIONARIO MÉDICO DE LA PERSONA ASEGURADA 3 A) Ha usted alguna vez solicitado una póliza de seguro que haya sido restringida, declinada o rechazada? B) Usted alguna vez ha sido diagnosticado o tratado para algunas de las siguientes condiciones? i. Enfermedad o trastorno del corazón, arterias, venas, sistema cardiovascular, embolia, presión alta, tumores, cáncer o diabetes. ii. Algún otro trastorno psicofísico no mencionado anteriormente? C) Usted ha sido diagnosticado o tratado por un profesional médico por el Síndrome de Inmunodeficiencia adquirido (SIDA) o cualquier complicación relacionada a este? D) Ha usted participado o tiene intenciones de participar en algún deporte o actividad riesgosa incluyendo pero no limitado a: paracaidismo, parapente, ala delta, vuelo en planeadores, globos aerostáticos o aviones ultraligeros, o cualquier otro vuelo que no sea como pasajero en un vuelo comercial regular, buceo, snorkeling, automovilismo o motociclismo de competición o recreación? SI SI SI SI SI E) Si respondió afirmativamente a cualquiera de estas preguntas, favor proveer detalles a continuación (incluyendo si correspondiese el nombre, dirección y teléfono/fax de su/s médico/s). Si es necesario, anexe una hoja adicional. ADDITIONAL INFORMATION / INFORMACIÓN ADICIONAL Indique si la Persona Asegurada es actualmente o fue: (A) un militar de alto rango, funcionario gubernamental o político de un país distinto a los EE.UU., ó (B) está 4 estrechamente asociada con un funcionario de dichas características o es un miembro de su familia inmediata. Si respondió afirmativamente, favor proveer detalles a continuación: SI DECLARATION / DECLARACIÓN 5 6 I/We, the undersigned, as Plan Participant(s) and Insured, if other than Plan Participant(s), hereby certify that all the information provided above is true and correct. Yo/Nosotros, el/los que firma(n) el presente documento como Participante(s) del Plan y Asegurado(s), en caso de no ser el/los Participante(s) del Plan, certifico(amos) que toda la información provista es verdadera y correcta. INSURED SIGNATURE (if other than Plan Participant(s)) / FIRMA DEL ASEGURADO (en caso de no ser el/los Participante(s) del Plan) SIGNATURE FIRMA SIGNATURE(S) / FIRMA(S) PLAN PARTICIPANT S SIGNATURE FIRMA DEL PARTICIPANTE DEL PLAN 7 JOINT PLAN PARTICIPANT S SIGNATURE FIRMA DEL CO-PARTICIPANTE DEL PLAN INTRODUCER S SIGNATURE FIRMA DEL INTRODUCTOR INTRODUCER CODE CÓDIGO DEL INTRODUCTOR Copyright 2015 Investors Trust Assurance SPC Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated Secure by A.M. Best Company. For the latest rating, access Investors Trust Assurance SPC is a member of The Association of International Life Offices (AILO). For more information, please visit: If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands. insured person Version 05/2015

12 1 PLAN PARTICIPANT INFORMATION / INFORMACIÓN DEL PARTICIPANTE DEL PLAN PLAN PARTICIPANT S NAME MBRE DEL PARTICIPANTE DEL PLAN JOINT PLAN PARTICIPANT S NAME MBRE DEL CO-PARTICIPANTE DEL PLAN FORM IP114-2 PAYMENT AUTHORIZATION AUTORIZACIÓN DE PAGO Complete this Form to Select or Update Payment Information Complete este Formulario para Seleccionar o Actualizar la información de Pago DATE FECHA POLICY NUMBER* NÚMERO DE PÓLIZA* PAYMENT INFORMATION / INFORMACIÓN DE PAGO 2 Please check one / Por favor seleccione una opción: a. By checking this box, I authorize Investors Trust to make a one-time debit only from my account (credit card or bank account) for the amount of Selecciono esta opción para autorizar a Investors Trust a realizar un cargo único a mi cuenta (tarjeta de crédito o cuenta bancaria) por la cantidad de SELECT CURRENCY Seleccione la moneda USD $ EUR GBP ENTER ONE-TIME CONTRIBUTION AMOUNT Introduzca monto para un cargo único,. b. By checking this box, I authorize Investors Trust to debit from my account (credit card or bank account) or Flex Plan policy all future scheduled contribution payments to my investment plan. Selecciono esta opción para autorizar a Investors Trust a debitar de mi cuenta (tarjeta de crédito o cuenta bancaria) o de la póliza Flex Plan, los futuros cargos recurrentes de contribuciones programadas a mi plan de inversión. c. By checking this box, I authorize Investors Trust to debit from my account (credit card or bank account) or Flex Plan policy all pending and future scheduled contribution payments to my investment plan. Selecciono esta opción para autorizar a Investors Trust a debitar de mi cuenta (tarjeta de crédito o cuenta bancaria)o de la póliza Flex Plan, todos los cargos pendientes y futuros cargos recurrentes de contribuciones programadas a mi plan de inversión. PAYMENT FRECUENCY (To be completed if 2b or 2c is selected) / FRECUENCIA DE PAGO (Para ser completado si la opción 2b o 2c ha sido seleccionada) 3 ANNUALLY ANUAL SEMI-ANNUALLY SEMESTRAL QUARTERLY TRIMESTRAL MONTHLY (CREDIT CARD, DIRECT DEBIT or FLEX DEBIT ONLY) MENSUAL (Tarjeta de crédito, débito directo y débito del Flex Plan únicamente) PAYOR INFORMATION /INFORMACION DEL PAGADOR 4 PLAN PARTICIPANT PARTICIPANTE DEL PLAN JOINT PLAN PARTICIPANT CO-PARTICIPANTE DEL PLAN OTHER (Please complete Addendum, section A) OTROS (Por favor complete el anexo, sección A) PAYMENT METHOD / MÉTODO DE PAGO CHECK OR WIRE TRANSFER / CHEQUE Ó TRANSFERENCIA ELECTRÓNICA 5 5a The company will send an notification prior to the due date of your next payment. / La Compañía enviará notificaciones por correo electrónico previo a la fecha de vencimiento de su próxima contribución. CREDIT CARD / TARJETA DE CRÉDITO 5b CREDIT CARD TYPE / TIPO DE TARJETA DE CRÉDITO CREDIT CARD NUMBER / NÜMERO TARJETA DE CRÉDITO EXPIRATION DATE / FECHA DE VENCIMIENTO American Express Visa Discover Diners Club MasterCard JCB Please note that credit cards like Visa, MasterCard, & American Express will be charged according to the currency of the product, and all other credit cards will be billed in U.S. Dollars. Credit card debits are limited to amounts below USD 25,000 (or the equivalent amount in EUR or GBP. Por favor notar que Tarjetas de Crédito como Visa, MasterCard, y American Express, serán cargadas de acuerdo a la moneda del producto, y todas las otras Tarjetas de Crédito serán facturadas en dólares US. Los débitos de tarjeta de crédito están limitados a montos inferiores a USD (o equivalente en EUR o GBP). DIRECT DEBIT FROM US BANK ACCOUNT / DÉBITO DIRECTO DESDE CUENTA DE CHEQUES 5c As a convenience to me, I hereby request and authorize Investors Trust Assurance, SPC (the Company ) to withdraw the amount indicated from the banking account entered below. If any withdrawal is not honored by the banking institution (the Bank ) whether with or without cause and whether intentionally or inadvertently, the Bank shall be under no liability whatsoever and I may be responsible for a returned check fee. I agree that the Bank s rights in respect to such draft shall be the same as if it were a check drawn on the bank and signed personally by me. Should any draft not be honored by the Bank upon presentation, I understand that this method of payment may be terminated. I understand also that my policy may lapse if said draft is returned unpaid by the Bank or discontinue payments prior to receiving confirmation of the draft processing from the Company. Como conviene a mi persona, solicito y autorizo a Investors Trust Assurance, SPC (la Compañía) a debitar la cantidad indicada de la cuenta bancaria ingresada a continuación. Si el débito no es aceptado por la institución bancaria (el Banco ) ya sea con o sin causa y ya sea intencional o inadvertidamente, el Banco no tendrá ninguna responsabilidad en absoluto y yo puedo ser responsable por el cargo de la transacción devuelta. Estoy de acuerdo que los derechos del Banco en respecto a tal giro serán igual que como si fuera un cheque girado sobre el banco y firmado por mí. Si cualquier giro no fuese honrado por el Banco a la hora de su presentación, yo entiendo que este método de pago podría ser cancelado. Yo también entiendo de que mi Póliza puede caducar si tal giro es devuelto por el Banco o si los pagos son descontinuados antes de recibir confirmación del procesamiento del giro de parte de la Compañía. ACCOUNT NUMBER / NÚMERO DE CUENTA ROUTING OR ABA NUMBER / NÚMERO DE ABA (attach void check on Addendum, section B / adjunte un cheque anulado en el anexo, sección B) EURO/GBP amounts will be debited in U.S. Dollars, subject to conversion rate as posted on the website. This service is only available via U.S. banks. Direct debit from US bank accounts are limited to amounts below USD 100,000. / Montos en EUR/GBP serán debitados en dólares US, de acuerdo a la tasa de conversión publicada en la página web. Este servicio está disponible solo a través de bancos en los Estados Unidos. Se aceptan débitos directos de cuentas de bancos de EE.UU. por cantidades menores a USD FLEX PLAN DEBIT / DÉBITO DEL FLEX PLAN ENTER THE POLICY NUMBER TO BE DEBITED / INGRESE EL NÚMERO DE PÓLIZA A SER DEBITADA 5d T S P Flex Plan debits are only allowed for automatic recurring payments (Either 2b or 2c must be selected). One -time debits (2a) from a Flex Plan are not allowed; the plan participant(s) must submit Form IP120 - Surrender Request. Débitos del Flex Plan solo están permitidos para débitos automáticos recurrentes (Opción 2b o 2c deben ser seleccionadas). Débitos únicos (2a) del Flex Plan no están permitidos; el participante(s) del plan debe enviar el formulario IP120 - Surrender Request. Transaction Cost: A surcharge may apply depending on the payment method selected. Please review form IG138-1 or IG140-1 for more details. Costo de Transacción: Un cargo podrá ser aplicado dependiendo de la tarjeta de crédito y del producto de inversión seleccionado. Por favor revise el formulario IGI38-2 o IG140-2 para más detalles. SIGNATURE(S) / FIRMA(S) 6 PLAN PARTICIPANT S SIGNATURE FIRMA DEL PARTICIPANTE DEL PLAN JOINT PLAN PARTICIPANT S SIGNATURE FIRMA DEL C0-PARTICIPANTE DEL PLAN INTRODUCER S SIGNATURE FIRMA DEL INTRODUCTOR INTRODUCER S SIGNATURE FIRMA DEL INTRODUCTOR *If the action requested herein involves a Capital Redemption product, the term Contract shall be deemed to be substituted for the term Policy wherever the term Policy appears in this document. *Si la acción solicitada en este documento involucra al producto de Capital Redemption, el término contrato se considerará que se sustituya por el término Póliza siempre que el término Póliza aparezca en este documento. Copyright 2015 Investors Trust Assurance SPC Investors Trust Assurance SPC is a Cayman Islands insurance company providing a variety of offshore wealth management solutions to investors around the world. These solutions support successful and vibrant retirement investment portfolios. Investors Trust works exclusively through independent financial advisers. Investors Trust is a registered trademark of Investors Trust Assurance SPC. Investors Trust Assurance SPC is regulated by the Cayman Islands Monetary Authority. For more information, please visit: If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands. payment authorization Version 05/2015

13 FORM IP114-2 PAYMENT AUTHORIZATION AUTORIZACIÓN DE PAGO Addendum / Anexo PAYOR INFORMATION / INFORMACIÓN DEL PAGADOR A RELATIONSHIP TO PLAN PARTICIPANT RELACIÓN CON EL PARTICIPANTE DEL PLAN LAST NAME / Apellido FIRST NAME / Primer Nombre MIDDLE NAME / Segundo Nombre COUNTRY OF NATIONALITY / País de Nacionalidad PASSPORT / ID # / No. de Pasaporte PASSPORT / ID DATE OF ISSUE / Fecha de Emisión PASSPORT / ID DATE OF EXPIRY / Fecha de Expiración CITY / Ciudad GENDER / Género MALE / Masculino FEMALE / Femenino TYPE OF ADDRESS / Tipo de Dirección BUSINESS / RESIDENTIAL / Comercial Residencial STATE OR PROVINCE / Estado o Provincia ADDRESS / Dirección ZIP CODE / Código Postal COUNTRY / País MOBILE TELEPHONE / Teléfono Móvil FAX TELEPHONE / Teléfono Fax HOME TELEPHONE / Teléfono de Residencia BUSINESS TELEPHONE / Teléfono Comercial / Correo Electrónico OCCUPATION / Ocupación PAYOR S SIGNATURE (if different from Plan Participant(s)) FIRMA DEL PAGADOR (en caso que sea diferente al Participante del Plan) B ATTACH VOID CHECK OR DEPOSIT SLIP HERE INCLUYA EL CHEQUE ANULADO Ó LA PLANILLA DE DEPOSITO Copyright 2015 Investors Trust Assurance SPC Investors Trust Assurance SPC is a Cayman Islands insurance company providing a variety of offshore wealth management solutions to investors around the world. These solutions support successful and vibrant retirement investment portfolios. Investors Trust works exclusively through independent financial advisers. Investors Trust is a registered trademark of Investors Trust Assurance SPC. Investors Trust Assurance SPC is regulated by the Cayman Islands Monetary Authority. For more information, please visit: If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands. LA TRADUCCIÓN DE ESTE DOCUMENTO A OTRO IDIOMA DISTINTO AL INGLES, TIENE EL ÚNICO PROPÓSITO DE FACILITAR LA COMPRENSIÓN DE DICHO DOCUMENTO A INDIVIDUOS QUE TIENE COCIMIENTO DEL IDIOMA INGLES. NUESTRA INTENCIÓN ES DE PROVEER LA TRADUCCIÓN MAS PRECISA POSIBLE DEL DOCUMENTO ORIGINAL EN INGLES, PERO DADO A DIFICULTADOS DE INTERPRETACIÓN, PUEDEN EXISTIR PEQUEÑAS DISCREPANCIAS DE LENGUAJE. ASUMIMOS RESPONSABILIDAD POR LA PRECISIÓN DE LA TRASCRIPCIÓN, Y DECLINAMOS LA OBLIGACIÓN ANTE CUALQUIER RECLAMO. payment authorization Version 05/2015 Addendum

14 FORM IN100-2 CLIENT ACCEPTANCE DECLARATION CARTA DE COMPROMISO DE INVERSIÓN To be completed by the Applicant(s). Please read the policy details prior to completing this form. To be completed for ALL Regular Premium cases of USD$ / EUR / GBP 10,000 or greater. Para ser completado por el/los Participante(s) del Plan. Por favor lea los detalles de la póliza antes de completar este formulario. Para ser completado en TODOS los casos de Contribuciones Regulares mayores a USD$ / EUR / GBP 10,000. PLAN PARTICIPANT INFORMATION / INFORMACIÓN DEL PARTICIPANTE DEL PLAN PLAN PARTICIPANT S NAME MBRE DEL PARTICIPANTE DEL PLAN 1 JOINT PLAN PARTICIPANT S NAME MBRE DEL CO-PARTICIPANTE DEL PLAN DATE FECHA DECLARATION / DECLARACIÓN 2 DEAR CLIENT a. POLICY / LOAN ESTIMADO CLIENTE: Please read the following statements carefully in order to ensure your investment privileges. Por favor lea detalladamente las siguientes declaraciones para asegurar sus privilegios de inversión. I/WE, THE PLAN PARTICIPANT(S) AS INDICATED ABOVE, UNDERSTAND AND ACKWLEDGE: / YO/SOTROS, EL/LOS PARTICIPANTE(S) DEL PLAN ARRIBA MENCIONADO, ENTIENDO(EMOS) Y DECLARO(MOS): INTRODUCER NAME / MBRE DEL INTRODUCTOR 1. My independent Introducer,, has explained to me the charges and fees associated with this Policy. I/We have reviewed this Subscription Agreement and all other relevant information contained in the illustration and product brochure. Mi Introductor, me/nos ha explicado la estructura de los cargos y costos asociados con esta Póliza. Yo/Nosotros he(mos) revisado el Acuerdo de Suscripción y toda la información relevante contenida en la Ilustración y el folleto del producto. 2. This Subscription Agreement is for the purpose of investing in a Policy with an annual Premium of Este Acuerdo de Subscripción tiene como fin la inversión en una Póliza con contribuciones anuales de Select currency Seleccione la moneda USD $ EUR GBP Enter annual premium amount Ingrese el monto de la contribución anual,. Policy Term Término de la Póliza 5 years/años 3. This is a 10 years/años Regular Premium Policy that requires me/us to make annual contributions during the entire life of the Policy. 15 years/años Poliza de de contribuciones regulares que requiere que realice(mos) contribuciones anuales durante todo el término de la Póliza. 20 years/años 25 years/años 4. The cost structure of the Policy includes the monthly Policy Fee, monthly Asset Management Fee and annual Administration Charge. La estructura de cargos de la Póliza incluye el Cargo de la Póliza mensual, el Cargo de Administración de Inversiones mensual y el Cargo de Administración anual. 5. The Policy may have little to zero surrender value, due to Surrender Charges, if the Policy is surrendered during the early years of the Policy life. La Póliza podría no tener o tener un muy bajo valor de rescate, debido a los Cargos por Rescate, si se realiza un rescate de la Póliza durante los primeros años del término de la misma. 6. This Policy includes a Loyalty Bonus on years 10, 15, 20 and 25, applicable according to the duration (full contribution payment term) of the Policy. However, this bonus will be forfeited if the terms and conditions as specified by the Company are not met. (There will be no Loyalty Bonus for full contribution payment terms less than 10 years.) Este producto incluye una Bonificación por Lealtad en los años 10, 15, 20 y 25, la cual será aplicada de acuerdo al término completo de contribución de la Póliza. Sin embargo, esta bonificación se podría perder si los términos y condiciones especificados por la Compañía no son cumplidos. (No habrá Bonificación por Lealtad en planes con términos de contribución menores a 10 años). 7. This Policy is invested in mutual funds; the returns of which are not guaranteed and depend purely on market performance. (Only applicable plans with these funds selected and Evolution product.) Esta Póliza invierte en fondos mutuos, los cuales no tienen un rendimiento garantizado y dependen exclusivamente de la rentabilidad del mercado. (Solo aplica para los planes con estos fondos seleccionados y para los productos Evolution). 8. The Plan Participant(s) indistinctly may be subject to a phone interview performed by the Company for quality control and security purposes. El/Los Participante(s) del Plan, indistintamente, estará(n) sujeto(s) a una entrevista telefónica realizada por la Compañía por motivos de seguridad y control de calidad. SIGNATURE(S) / FIRMA(S) PLAN PARTICIPANT S SIGNATURE FIRMA DEL PARTICIPANTE DEL PLAN 3 JOINT PLAN PARTICIPANT S SIGNATURE FIRMA DEL CO-PARTICIPANTE DEL PLAN INTRODUCER S SIGNATURE FIRMA DEL INTRODUCTOR INTRODUCER CODE CÓDIGO DEL INTRODUCTOR Copyright 2015 Investors Trust Assurance SPC Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated Secure by A.M. Best Company. For the latest rating, access Investors Trust Assurance SPC is a member of The Association of International Life Offices (AILO). For more information, please visit: If you have any questions, please use the Contact Us feature on the Investors Trust website (this web site contains information about products that are not authorized in the United States and therefore not available to United States person(s)) or contact your servicing Introducer. You may also contact us at Suite 4210, 2nd Floor, Canella Court, Camana Bay, P.O. Box 32203, Grand Cayman KY1-1208, Cayman Islands. I NIV N E V S T E O S T R O S RTS RTU R S U T S T client acceptance declaration

15 Investors Trust is a registered trademark of Investors Trust Assurance SPC, rated Secure by A.M. Best Company. For the latest rating, access Investors Trust Assurance SPC is a member of the Association of International Life Offices (AILO). The contents are not to be reproduced or distributed to the public or press. Please consult your own legal, tax or investment professional before making any financial decisions. Investors Trust es una marca registrada de Investors Trust Assurance SPC, calificada Segura por A.M. Best Company. Para obtener la calificación más actualizada, visite Investors Trust Assurance SPC es miembro de la Association of International Life Offices (AILO). Este documento no puede ser reproducido o distribuido al público o prensa. Antes de tomar cualquier decisión financiera, consulte con un asesor profesional para obtener información sobre regulaciones legales, impuestos y/o planificación financiera. Third party trademarks are used with the permission of their owners. Las marcas registradas de terceros son utilizadas con el permiso de sus dueños.

16 For Inquires write to / Para consultas escriba a: Investors Trust Assurance SPC, Suite 4210, 2nd Floor, Canella Court, Camana Bay PO Box Grand Cayman, KY Cayman Islands Or / Contáctenos por correo electrónico a: info@investors-trust.com