Important Facts Statement And Applicant s Declarations Investment- Linked Assurance Scheme ( ILAS ) Policy Agent s/intermediary s name / Agent s/intermediary s contact phone no. / Agent s/intermediary s code / Agency Policy No.: Insured: Policyowner (if other than Insured): Chubb Life Insurance Company Ltd. Name of the ILAS Policy: WealthMaster Variable Universal Life (WMVUL) PART I: Important Facts Statement You should carefully consider the information in this statement and the product documents (including the Product Brochure, Investment Options Brochure and Product Key Facts Statement). If you do not understand any of the following paragraphs or do not agree to that particular paragraph or what your agent has told you is different from what you have read in this statement, please do not sign the confirmation and do not purchase the ILAS policy. You may request the Chinese version of this statement from your agent. I have selected to use the English version to complete this statement. SOME IMPORTANT FACTS YOU SHOULD KNOW (1) Statement of Purpose: Please set out in your own handwriting your reasons/ considerations for making this *(Additional Planned Premium/Extra Contribution/ Unscheduled Contribution). The agent is required to take due account of the reasons/ considerations set out by you, together with other relevant information, in assessing whether making this *(Additional Planned Premium/Extra Contribution/Unscheduled Contribution) is suitable for you. I confirm that I have read and understood and agree to be bound by paragraphs (1) above. *Delete as appropriate NB266A/0516/IC 1 of 13
(2) No ownership of assets and no guarantee for investment returns: You do not have any rights to or ownership over any of the underlying investment assets of this ILAS policy. Your recourse is against Chubb Life Insurance Company Ltd. only. You are subject to the credit risk of Chubb Life Insurance Company Ltd.. Investment returns are not guaranteed. (3) Long-term features: (a) Upfront charges: A Premium Charge will be deducted upfront from the premiums/ contributions you pay as charges and will not be available for investment. This means that the remaining amount of premiums/contributions available for investment will be lower than your premiums/contributions paid. The Premium Charge is calculated as follows: Premium Charge = Premiums/Contributions received X Premium Charge % Planned Premium/Additional Planned Premium Year from policy date of Planned Premium/effective date of Additional Planned Premium Premium Charge % 1st year: 22% 78% 2nd 10th year: 5% 95% 11th year or after waived 100% Extra Contribution/Unscheduled Contribution % of premium received available for investment after Premium Charge Policy year Premium Charge % % of contribution received available for investment after Premium Charge All years 5% 95% I confirm that I have read and understood and agree to be bound by paragraphs (2) and (3a) above. I understand and accept all the fees and charges, including the upfront charges and early surrender/withdrawal charges. 2 of 13
(b) Early surrender/withdrawal charges: You will be subject to a Surrender Charge, if surrender or partial withdrawal from Planned Premium Account occurs within a prescribed period before the end of the policy term. The Surrender Charge is calculated as follows: Surrender Charge = Planned Premium Account Value surrendered/withdrawn X Surrender Charge % No. of months^ Surrender Charge % No. of months^ Surrender Charge % 1 12 100% 73 84 19% 13 24 90% 85 96 14% 25 36 76% 97 108 10% 37 48 49% 109 120 5% 49 60 35% 121 or more 0% 61 72 26% ^ Number of months refers to the actual number of months of initial monthly Planned Premium received since the policy date for the basic portion or the actual number of months of relevant initial monthly Additional Planned Premium received, since the effective date of addition for each additional portion. (4) Fees and charges: Some fees/charges will be deducted from the premiums/ contributions you pay and/or your ILAS policy value, and will reduce the amount available for investment. Accordingly, the return on your ILAS policy as a whole may considerably be lower than the return of the underlying funds you selected. For details, please refer to the product documents of this ILAS policy. (5) Switching of Investment: If you switch your investment choices, you may be subject to a charge and your risk may be increased or decreased. (6) Premium holiday: Please check with your agent and the product documents whether and under what specific conditions a premium holiday (during which premium payment is suspended) may be taken. If your ILAS policy allows a premium holiday, you should note that: (a) Premium holiday means that you may temporarily suspend your regular premium payments. (b) As all relevant fees and charges will continue to be deducted from your ILAS policy value during the premium holiday, the value of your ILAS policy may be significantly reduced. I confirm that I have read and understood and agree to be bound by paragraphs (3b), (4), (5) and (6) above. I understand and accept all the fees and charges, including the upfront charges and early surrender/withdrawal charges. 3 of 13
(7) Risk of early termination: Your ILAS policy may be automatically early terminated and you could lose all your premiums/contributions paid and benefits accrued if any condition of automatic early termination is triggered. This may happen if you fail to make premium contribution (for regular premium payment), or if your policy has very low or negative value (e.g. poor investment performance, exercise of premium holiday), etc. (8) Intermediaries Remuneration: If you pay *(Additional Planned Premium/Extra Contribution/Unscheduled Contribution) under your ILAS policy, the agent will on average receive remuneration of: * For Additional Planned Premium - $2.9 per $100 of the Additional Planned Premium that you pay * For Extra Contribution - $2.7 per $100 of the Extra Contribution that you pay * For Unscheduled Contribution - $2.7 per $100 of the Unscheduled Contribution that you pay The above remuneration is an average figure which covers all payments to the agent directly attributable to your contribution of the *(Additional Planned Premium/Extra Contribution/Unscheduled Contribution) (including upfront and future commissions, bonuses and other incentives). * In respect of the Additional Planned Premium, 1. The average figure is calculated on the assumption that you will pay all the Additional Planned Premium throughout the entire premium payment period; 2. The amount of remuneration actually receivable by the agent in relation to your contribution of the Additional Planned Premium may vary from year to year and is higher in the first year/early years from the effective date of the increase in Planned Premium; and 3. As this policy involves whole-life premium payment, a 30-year period has been adopted for calculating both the total Additional Planned Premium and the total remuneration. Certain benefi ts that are immaterial, not directly attributable to your contribution of the *(Additional Planned Premium/Extra Contribution/Unscheduled Contribution) and not readily convertible to cash are not included from the calculation Please consult your agent if you wish to know more about the remuneration that he/she/ they may receive in respect of this policy. I confirm that I have read and understood and agree to be bound by paragraphs (7) and (8) above. *Delete as appropriate 4 of 13
Glossary Additional Planned Premium Extra Contribution Planned Premium Planned Premium Account Planned Premium Account Value Unscheduled Contribution means each increase of Planned Premium. means the regular contribution of premium on top of the Planned Premium plus supplementary benefit premium (if any), which is to be invested in the underlying fund you selected after the deduction of any applicable fees and charges. means the basic premium of the ILAS policy for investment in underlying fund you selected after the deduction of any applicable fees and charges. means the account used to maintain the units as allocated with the Planned Premium or Additional Planned Premium paid after deduction of any applicable fees and charges. means the sum of the values of all balances in the respective investment options of Planned Premium Account where the value of each such balance is calculated by multiplying the selling price for the relevant investment option by the ILAS policy s unit balance in respect of that investment option. means the contribution(s) of premium, in addition to the Planned Premium and supplementary benefit premium (if any) and the Extra Contribution (if any), for investment in underlying fund you selected after deduction of any applicable fees and charges. PART II: Policyowner s Declarations Section I: Disclosure Declaration (name and registration number), has conducted a Financial Needs Analysis and Risk Profiling Questionnaire for me. adjustment, where the insurer has the right and absolute discretion under certain situations (e.g. early policy surrender) to apply a downward/negative market value adjustment to the ILAS policy. 5 of 13
# Section II: Affordability Declaration (For regular premium payment) premium payments for the entire payment term of the ILAS policy; and policy. # You can delete if you apply for a single premium plan or one-off premium payment PART III: Suitability Declaration 1. I understand and agree that (tick one only): A the features and risk level of the ILAS policy and my selected mix of underlying investment choices are suitable for me based on my disclosed current needs and risk profile as indicated in the Financial Needs Analysis and Risk Profile Questionnaire. OR B despite the fact that the features and/or risk level of the ILAS policy and/or my selected mix of underlying investment choices may not be suitable for me based on my disclosed current needs & risk profile as indicated in the Financial Needs Analysis and Risk Profile Questionnaire, I confirm that it is my intention and desire to proceed with my application(s) as explained below: (If Box B is ticked, Applicant must complete explanation in own handwriting in this box.) I acknowledge I should not purchase this ILAS policy and/or make top-up investment to my existing ILAS policy and/or the selected mix of underlying investment choices unless I understand these and their suitability has been explained to me and that the final decision is mine. I confirm and understand that I am willing to bear the investment risk of this ILAS policy and/or top-up investment to my existing ILAS policy. 6 of 13
Please complete this section for retirees or customers aged over 55. I declare that the money to be invested in the policy throughout the whole policy term will not be used to maintain my standard of living and/or to fulfil my other financial commitments. I also confirm I understand and accept that surrendering the policy and/or making partial withdrawal from Planned Premium Account Value during the surrender charge period (which will end upon my payment of 121 months of initial monthly Planned Premium for the basic portion and upon my payment of 121 months of initial monthly Additional Planned Premium for each additional portion) will incur surrender charge, and declare that during the surrender charge period I have no immediate need of such amount to be invested in the policy. 2. Please complete this section for top up investment with Financial Needs Analysis and Risk Profile Questionnaire have been done. (a) I declare that Financial Needs Analysis and Risk Profile Questionnaire have been completed within 1 year for the policy number with a copy of the same attached. (b) I declare that there are no substantial changes in my circumstances, no mismatch in needs and risks tolerance level and affordability to the top up investment since the date when the above mentioned Financial Needs Analysis and Risk Profile Questionnaire were completed. Notes: 1. In this Statement & Declaration, the singular shall include the plural; the word I shall include we ; & the word my shall include our. For joint applicants, all applicants must sign all sections. 2. You are required to inform your insurance agent or us (the insurance company) if there is any Substantial change of information provided in these Declarations before the policy is issued. 7 of 13
Agent s/intermediary s name / Agent s/intermediary s contact phone no. / Agent s/intermediary s code / Agency : : ( ): : (WMVUL) : ( ) You may request the English version of this statement from your agent. I have selected to use the Chinese version to complete this statement. (1) : * ( / / ) / *( / / ) (2) : (1) (2) * NB266A/0516/IC 8 of 13
(3) : (a) : / : = / X % / % 1 22% 78% 2 10 5% 95% 11 100% (%) % (%) 5% 95% (b) : = / X % ^ % ^ % 1 12 100% 73 84 19% 13 24 90% 85 96 14% 25 36 76% 97 108 10% 37 48 49% 109 120 5% 49 60 35% 121 0% 61 72 26% ^ (4) : (3) (4) 9 of 13
(5) : (6) : ( ) : (a) (b) (7) : : ( : ) (8) : * ( ) : * - $2.9 ( $100 ) * - $2.7 ( $100 ) * - $2.7 ( $100 ) *( / / ) ( * 1. ; 2. / ; 3. *( ) (5) (6) (7) (8) * 10 of 13
( ) / ( ) ( ) : ( ) ( ) / # ( ) / ; # 11 of 13
: 1. : ( ) A OR B / / ( B ) / 55 / ( 121 121 ) 12 of 13
2. : (a) (b) : 1. ; ; 2. / 13 of 13