Discretionary Portfolio Service (DPS)

Application form
DPS is a wealth management solution administered by deVere Acuma Insurance Brokers (“deVere Acuma”)
consisting of risk rated portfolios of funds for you to choose from to invest the premiums paid into your
policy/policies with Zurich International Life Limited (“Zurich”).
Completing this form
This is an interactive PDF form. Please fill the form on your computer and print to sign the declaration. When completing the form manually,
use blue or black ink, write clearly in BLOCK CAPITAL letters and in English. If your application does not include all the information we need,
it will result in delays.
By completing this form you agree to start investing your new policy premiums and/or switch your current fund investments to the DPS portfolio
selected below.
For more information about DPS, please refer to the DPS brochure and DPS fund factsheets.

1. Investment details
Select one option per policy only

Option 1 – Invest your new or existing policy in a DPS portfolio.

Please mention the selected name and code clearly against each application/policy number.
Application/policy number DPS portfolio name DPS portfolio code

8453972 DPS4 B0151

The DPS portfolios available are: USD Portfolio name Code GBP Portfolio name Code
deVere DPS 1 USD B0148 deVere DPS 1 GBP B0152
deVere DPS 2 USD B0149 deVere DPS 2 GBP B0153
deVere DPS 3 USD B0150 deVere DPS 3 GBP B0154
deVere DPS 4 USD B0151 deVere DPS 4 GBP B0155

Please note that if you decide to change your selected DPS portolio in the future you will have to complete a new DPS application form.
Option 2 – For new business applications only
Create your own investment strategy (Use a combination of DPS portfolios and other investment funds available to your policy)

Policy number
Fund Name Fund Code Allocation %

Please ensure the total adds up to 100%  TOTAL

Option 3 – For your existing policy only

Switch funds of your existing policy and create your own investment strategy.

Policy number 8453972

Sell from the present fund holding Buy into new fund holding
Fund name Fund code Percentage to sell Fund name Fund code Percentage to buy

ADVENTUROUS ADUSD DPS4 B0151 100

BLUE CHIP BCUSD

PERFORMANCE PFUSD

DVAM GLB EQUITY USDYQ

Please ensure the total adds up to 100%  TOTAL 100.00

Redirect future payments

Select the funds where your future premiums will be invested.

Fund Name Fund Code Allocation %

DPS4 B0151 100

Please ensure the total adds up to 100%  TOTAL 100.00

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2. DPS portfolio administrator details
Company name deVere Acuma Insurance Brokers L.L.C.

Company registered address Level 35, 1 Sheikh Zayed Road, H Hotel Office Tower, PO Box 23940, Dubai, United Arab Emirates.
Other locations:
2201 Marina Plaza, Emaar Drive Dubai Marina, PO Box 75464 Dubai United Arab Emirates.
Tower 3 Level 27, Etihad Towers, Corniche Road, PO Box 6315, Abu Dhabi, United Arab Emirates.

Company regulation number 571 190

Company regulated by UAE Insurance Authority – registration number 190

3. Customer declaration
I/We request Zurich to switch and/or invest in the DPS portfolio as selected by me/us for the policy/policies stated on this form. I/We confirm that
I/we have received and read a copy of the DPS brochure.
I/We understand that deVere Acuma has selected the funds and will administer the DPS portfolio and provide instructions to Zurich accordingly.
I/We understand that my/our DPS portfolio investment(s) will incur a yearly administration fees of 1% and additional fund charges and confirm
that I/we have been provided with a copy of the brochure which includes written details of those charges.
I/We understand that the charges will be calculated and deducted daily using the current value of the underlying assets within each DPS portfolio
held in the policy/policies at the time in accordance with the charges set out in the brochure a copy of which has been provided to me/us by
deVere Acuma.

4. Important information
Before signing this form you should be aware that:
This form confirms the basis on which you have made the investment choices within your Zurich policy.
Zurich does not accept any responsibility in respect of the fund choice offered within the DPS portfolio which is administered by
deVere Acuma.
Zurich has absolute discretion to reject or accept investment instructions from deVere Acuma or you in respect of the DPS portfolios.
Zurich will not be liable for any loss caused to your policy as a consequence of Zurich acting on instructions received in connection with your
choice of or changes to the DPS portfolios.
The DPS portfolio will only comprise of assets that are offered by Zurich within the range of funds available for investment in connection with
your policy.
Zurich does not endorse the ability or suitability of any of the DPS portfolio that you choose.
Zurich is not responsible for the investment selection made by deVere Acuma in respect of the DPS portfolio in accordance with your
investment objectives and attitude to risk.
Zurich does not give advice on the financial or tax implications of changes to your policy.

5. Termination
This instruction to Zurich can be terminated at any time by switching out of the DPS portfolio. If you inform us that you are changing your
appointed financial adviser from deVere Acuma, we will ask you to select alternative investment funds for your current fund holding and for
your future premiums. You will need to provide Zurich a switch and redirection form or submit an online portfolio management request using
your secure ZIO account.

6. Privacy notice
The personal information requested in this form is collected and used by Zurich International Life Limited as Data Controller in line with the
Data Protection Policy. Full details can be found online at https://www.zurichinternational.com/en/zurich-international-life/aboutus/privacy or
contact us for a copy.

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7. Policy owner authorisation
I/We confirm that this/these signature(s) below is/are mine/ours or that/those of my/our appointed legal representative(s).

Policy owner/Authorised signatory 1 Policy owner/Authorised signatory 2

Signature Signature

Full name  Full name

Date D D M M Y Y Y Y Date D D M M Y Y Y Y

This section is only for completion by those acting on behalf of a company or trust
Name of the company/trust (policy owner)

Registered company number (if applicable)

Name of company/trustee representative for correspondence

8. DPS portfolio administrator – declaration and authorisation

We confirm that we have the necessary level of authorisation from the regulatory organisation to act in the capacity appointed and that we
will notify the policy owner and Zurich if this authorisation changes or any regulator disciplinary action is taken against us.
Notwithstanding any other terms under this agreement, no insurer shall be deemed to provide coverage or will make any payments or provide
any service or benefit to any insured or other party to the extent that such cover, payment, service, benefit and/or any business or activity of
the insured would violate any applicable trade or economic sanctions law or regulation.
We confirm that we have read and understood this DPS application form in conjunction with the DPS brochure setting out all the applicable
terms and conditions of the DPS.
On behalf of the DPS portfolio administrator company.

Authorised signatory
Signature

Full name of signatory SIDDHARTH BHATIA

Date D D M M Y Y Y Y
Important information
Zurich International Life is a business name of Zurich International Life Limited.
Zurich International Life Limited is fully authorised under the Isle of Man Insurance Act 2008 and is regulated
by the Isle of Man Financial Services Authority which ensures that the company has sound and professional
management and provision has been made to protect policy owners.
For life assurance companies authorised in the Isle of Man, the Isle of Man’s Life Assurance (Compensation
of Policyholders) Regulations 1991, ensure that in the event of a life assurance company being unable to
meet its liabilities to its policy owners, up to 90% of the liability to the protected policy owners will be
met. The protection only applies to the solvency of Zurich International Life Limited and does not extend to
protecting the value of the assets held within any unit-linked funds linked to your policy.
Not for sale to residents or nationals of the United States including any United States federally controlled territory.
Zurich International Life Limited is registered (Registration No. 63) under UAE Federal Law Number 6 of
2007, and its activities in the UAE are governed by such law.

Zurich International Life Limited provides life assurance, investment and protection products and is
authorised by the Isle of Man Financial Services Authority.
Registered in the Isle of Man number 20126C.
Registered office: Zurich House, Isle of Man Business Park, Douglas, Isle of Man, IM2 2QZ, British Isles.
Telephone +44 1624 662266 Telefax +44 1624 662038 www.zurichinternational.com

MSP13785 (720386002) (05/18) RRD