Unit Trust Funds

Application Form

Growing Wealth, A Day at A Time

We’re Better Together

 A) Key Information

Instructions will not be processed unless all requirements have been met, all relevant documentation received and the investment funds
reflected in ICEA LION's bank account.
Completed forms and the required documentation should be submitted customer service team to [email protected]. Please
note ALL U.S persons must attach the FATCA documents.
You will automatically be enrolled to receive e-Documents. Please provide your email address as a consent to operational and transactional
email communication.
Please review and read the Terms and Conditions document available on the last page of this document.
Please note neither ILAM nor any intermediaries are authorized to handle cash payments.

B) Documents to Attach

Copy of National ID/Passport

Copy of KRA PIN Certificate/ Tax Exemption Certificate
Proof of Bank Details (Copy of bank statement, Debit Card/cancelled cheque)
Utility Bill
Proof of payment (Attach source of funds confirmation for transactions above the equivalent of USD 15,000)
Registration certificate (corporates)

C) Private Individuals

Parents or guardians should sign in the case of a minor (under 18 years of age)

Details Applicant 1/ Junior Applicant 2 / Guardian

Name CYRUS MUTURI KAGUIMA TELLINE NJOKI MWANGI

Date of Birth 28-07-2001 Gender M • F 02-05-2002 Gender M
•
F

Postal Address N/A N/A

Nationality KENYAN KENYAN
Marital Status • Single Married Other
• Single Married Other
Mobile Number 0708-538-399 0748-236-283
Email Address [email protected] [email protected]
Passport/ID Number 38423254 40143022
KRA (PIN) A014618140U A019203158Z
Estate/Street/
House No. Kasarani, Nairobi Kamakis, Kiambu

Details Applicant 3 / Guardian Applicant 4/ Guardian

Name
Date of Birth Gender M F Gender M F

Postal Address
Nationality
Marital Status
Single Married Other Single Married Other
Mobile Number
Email Address
Passport/ID Number
KRA (PIN)
Estate/Street/
House No.

I write to confirm that the above information is a description of my current residential address. This description is provided as I do not
have any utility bill that may be used to verify my current residential address

ICEA LION Centre, Riverside Park Chiromo Road, Westlands Tel: +254 (0) 20 275 0000 | +254 719 071000 | +254 730 151000
P.O. Box 46143 – 00100 Nairobi Contact Centre: +254 719 071999 | +254 730 151999
Email: [email protected] www.icealion.co.ke
 D) Institutions (Companies, Trusts, Charities, Clubs, Religious Bodies, Schools, Chamas, Others)

Name of Institution

Type of Institution Registered No.

Organization’s Phone No. Email Address

Company PIN No. or EIN

Contact Person Name Mobile No.

Physical Address

E) Authorized Signatories

Details Signatory 1 .
Signatory 2

Title • Mr Mrs Miss Other M.r

• Mr.s Miss Other

Full Names CYRUS MUTURI KAGUIMA TELLINE NJOKI MWANGI

Date of Birth 28-07-2001 Gender M 02-05-2002 Gender F

Nationality KENYAN KENYAN

Marital Status Single Married Other Single Married Other

Phone No. 0708538399 0748236283

Email Address [email protected] [email protected]

Passport/ID No. 40143022

38423254

KRA Pin A014618140U A019203158Z

Signature

Details Signatory 3 .
Signatory 4

Title Mr Mrs Miss Other M.r Mr.s Miss Other

Full Names

Date of Birth Gender M Gender F

Nationality

Marital Status Single Married Other Single Married Other

Phone No.

Email Address

Passport/ID No.

KRA Pin

Signature

ICEA LION Centre, Riverside Park Chiromo Road, Westlands Tel: +254 (0) 20 275 0000 | +254 719 071000 | +254 730 151000
P.O. Box 46143 – 00100 Nairobi Contact Centre: +254 719 071999 | +254 730 151999
Email: [email protected] www.icealion.co.ke
 F) Foreign Account Tax Compliance Act (FATCA)

1. Are you a U.S. Resident? Yes

• No

2. Are you a U.S. Citizen? Yes

• No

3. Are you holding a U.S. Permanent Resident Card (Green Card)? Yes
• No

4. Were you born in the U.S? Yes • No

5. Have you granted power of attorney to a person with a U.S. address? Yes
• No

6. Do you have a U.S. residential address? Yes

• No

7. Do you have a correspondence, C/O or Hold mail address in the U.S? Yes
• No

8. Do you have a standing order to a U.S. Bank Account? Yes

• No

9. Do you have a U.S. telephone number? Yes

• No

Please note that the following documents MUST BE attached by all US persons
• Form W9 - U.S persons only
• Form W-8BEN - Non U.S persons only

G) Risk Assessment Questionnaire ( Indicate your choice in the box provided) Score

1. When you think of the word risk, what comes to your mind first?
3
Loss [1] Uncertainty [2] Opportunity [3] Thrill [4]

2. Have you ever invested in financial markets before? 2

No [1] Yes [2]

3. Approximately what portion of your total savings will this investment present?
4
Over 80% [1] 21 - 50% [2] 51 - 80% [3] 0 - 20% [4]

4. When making an investment, how long do you plan on holding it for?

3
0 - 1 years [1] 1 - 2 years [2] 3 - 5 years [3] 5 years [4]

5. Which one of the following most accurately describes your general attitude towards investing?
2
- In order to minimise fluctuations in my investments, I am willing to accept lower returns in the long run [1]
- I am willing to accept possible fluctuations in my investments in order to earn moderate returns over the long run [2]
- I am willing to accept larger fluctuations in my investments in order to earn above average potential returns over the long run [3]
- I am willing to accept large and potentially drastic fluctuations in my investments in order to earn higher potential returns over the long run [4]

6. If the value of your investment went down by 20%, what would you do?
I would buy more of the investment [1] I would sell some of the investment [2] 4
I would sell all of the investment [3] I would hold on to the investment [4]

7. When do you plan to begin withdrawing money from the investment? 0

0 - 1 years [1] 1 - 2 years [2] 3 - 5 years [3] 5 years [4]

8. How would you describe your investment style?

2
Conservative [1] Moderate [2] Aggressive [3]

9. How do you feel about the following statement?

Maintaining the principal of my investment account is more important than achieving significant growth 2
Strongly Agree [1] Agree [2] Somewhat Agree [3] Disagree [4]

10. As an investor during an economic downturn, how do you react?

1
- I would wait for things to start looking up, and then invest [1]
I would quickly sell off my existing investment [2]
-- I would immediately invest or add more money to my investment [3]
- I would hold all of my investment [4]

*Kindly tally your scores and compare with the risk matrix below.

ICEA LION Centre, Riverside Park Chiromo Road, Westlands Tel: +254 (0) 20 275 0000 | +254 719 071000 | +254 730 151000
P.O. Box 46143 – 00100 Nairobi Contact Centre: +254 719 071999 | +254 730 151999
Email: [email protected] www.icealion.co.ke
 Points 5 - 15 16 - 25 26 - 35
Risk Profile Conservative
Conservative investors are
Moderate
Moderate investors are usually
Aggressive •
Aggressive investors are long term
investors who want stability and medium term investors who investors who want high capital
are more concerned with protect- want to protect their capital and growth. Substantial year to year
ing their current investments. A achieve some real increase. The fluctuations in value are acceptable
conservative investor is generally investor is seeking a diversified in exchange for a potentially high
Seeking to Preserve capital and as portfolio with exposure to a long term return. An aggressive
a trade-off is usually prepared to broad range of investment investor is comfortable accepting
Risk Category Details accept lower investment returns. sectors. high volatility in their capital value,
with the risk of short to medium term
periods of negative returns. They are
willing to trade higher risk for greater
long term returns and typically will
have a long investment objective.

H) Fund Details

Initial investment amount 3,500

Select the fund to be invested in
Minimum investment amount: Ksh.500 or USD 500 for the USD fixed Income fund

Money Market Fund •

Amount......................................
Balanced Fund
Amount....................................
Equity Fund USD Fixed Income Fund Bond Fund
Amount.................................. Amount.............................................. Amount...................................

I) Source of Funds (to be completed by all applicants)

Salary/savings • Pension Betting/Lottery Donation/Gift/Inheritance

Sale of an investment
Rental/disposal property Loan Other (please specify)
portfolio

J) Applicant(s) Bank Details

Bank Name Bank Address

Account Holder’s Name Swift Code

Branch Name Bank Code

Account Number Account Type

*Please note: We do not make 3rd party payments.

Any change of Bank Details above must be provided in writing with adequate proof and the relevant KYC documents attached

K) Bank Account Details

NOTE: All cash payments must be made at the bank or through our business paybill number.
International payments: (Swift Code - SCBLKENX XXX)

Branch Clearing
Fund Account number Bank Branch
No. Code
ICEA LION Money Market Fund 0105016760900 Standard Chartered Bank Chiromo 078 02
ICEA LION Balanced Fund 0105016761000 Standard Chartered Bank Chiromo 078 02
ICEA LION Equity Fund 0105016761100 Standard Chartered Bank Chiromo 078 02
ICEA LION Bond Fund 0105016761300 Standard Chartered Bank Chiromo 078 02
ICEA LION USD Fixed Income 8705016760302 Standard Chartered Bank Kenyatta Avenue 006 02
Fund -Inflow Account

For M-pesa PayBill

Paybill Business No Paybill Account No
The account number is your six digit member number(xxxxxx)
974200
preceded by the initials of the fund e.g.
Money Market - MMFxxxxxx
Equity Fund - EFxxxxxx
Balanced Fund - GFxxxxxx
Bond Fund - BFxxxxxx

ICEA LION Centre, Riverside Park Chiromo Road, Westlands Tel: +254 (0) 20 275 0000 | +254 719 071204 | +254 730 151000
P.O. Box 46143 – 00100 Nairobi Contact Centre: +254 719 071999 | +254 730 151999
Email: [email protected] www.icealion.co.ke
 L) Beneficiaries

The Client instructs that in the event of death prior to termination of this agreement or death after the termination of the agreement, any
funds and securities held by ILAM shall be held in Trust to be paid to the beneficiaries listed below:

Adittional Information

Telephone Proportion
Full Name ID Number Physical Address Relationship (if any)
Number of benefits
Edith Kaguima Muthoni N/A Nairobi, Kenya 0705715539 Sister 50%
Ann Waithira 22000271 Kiambu, Kenya 0722211686 Mother 50%

Guardian for beneficiaries under the age of 18 years

Full Name ID Number Physical Address Telephone Number Relationship (if any)

In case of a Junior account, I confirm that the Applicant 1/Junior is the beneficial owner of the shares being purchased

*If minor, please provide a copy of the minor’s birth certificate or baptism card (in the absence of a birth certificate)

M) Correspondence
Please tick how you would like to receive communication such as statements, updates, etc.

• E-mail Text message whatsApp channel

N) (a) Signing Arrangement / Account Mandate (Individual & Joint)

All instructions to ICEA LION Asset Management regarding this account must be given by:

The Applicant/guardian only

All applicants/all guardians (incase of joint account) •
Either applicant/Either guardian (incase of multiple account)

Special signing arrangement (please specify).........................................................................................................................................................................

I / We the undersigned confirm that we have read and understood this declaration and its implications.
CYRUS MUTURI KAGUIMA 07-02-2025
Applicants Name 1..............................................................................Signature....................................................Date........................................................
TELLINE NJOKI MWANGI 07-02-2025
Applicants Name 2 ..............................................................................Signature....................................................Date........................................................
Applicants Name 3..............................................................................Signature....................................................Date........................................................
Applicants Name 4..............................................................................Signature....................................................Date........................................................

N) (b) Signing Arrangement / Account Mandate (Corporate)

All instructions to ICEA LION Asset Management regarding this account must be given by:
•
Any one authorised person
Any two authorised persons

All authorised persons

•
Special signing arrangement (please specify)..........................................................................................................................................................

I / We the undersigned confirm that we have read and understood this declaration.
Director 1.............................................................................................Signature....................................................Date........................................................
Director 2 ...........................................................................................Signature....................................................Date........................................................
Director 3...........................................................................................Signature....................................................Date........................................................
Director 4...........................................................................................Signature....................................................Date........................................................

ICEA LION Centre, Riverside Park Chiromo Road, Westlands Tel: +254 (0) 20 275 0000 | +254 719 071000 | +254 730 151000
P.O. Box 46143 – 00100 Nairobi Contact Centre: +254 719 071999 | +254 730 151999
Email: [email protected] www.icealion.co.ke
 0)For o cial use only

i)Agency Information:

Introducing Agent; I confirm that all the above documents have been attached
Agent’s Name Tel Number E-mail Agent’s Code No. Agent’s Signature

ii)Account Opening O cer

AML Risk Category Review Date PEP Status

Received / Confirmed by Date DD M YYYY

P)Terms & Conditions

1.)Applicants must complete all sections, disclosing and providing all relevant information and documentation. Failure to do so may result in a delay in
the processing of the application. Further information may be required during the verification process (i.e. questions arising from the information
provided). A purchase note will be issued once requisite documentation has been received and verified and the funds have been invested.
In case of any mistakes while completing the form, kindly cross out the error and write the new information clearly. The investor
completing the form must countersign each correction.
2.)
Units are traded at the daily price and will be repurchased by the fund administrator, ICEA LION Asset Management Limited, in
accordance with the Capital Markets (Collective Investment Schemes) Regulations and the terms and conditions set out in the relevant
3.) Trust Deed.

Completed application forms and notification of deposit/cleared funds must be received for the investment to be executed. (In the case of an
investment by a minor, please provide a copy of the minor’s birth certificate or baptism card (in the absence of a birth
4.)
certificate)
The investor applies to invest in one of the sub-funds of the collective investment scheme (the ICEA LION Unit Trust Fund) in accordance
with the provisions of the Umbrella Trust Deed and the respective supplemental Trust Deed. This will be at the net asset value (NAV) at
5.) the close of business on the date of receipt of the funds and application form by ICEA LION Asset Management Limited, provided it is
received by the close of business the previous day. Otherwise, the following day’s net asset value will be used to calculate the purchase
value of the respective unit trust product(s).

The investor and/or his/her financial advisor shall at all times be responsible for ensuring that the unit trust and its representatives receive
any instructions from the investor and/or financial advisor, whether by hard copy or email, and that such instructions are complete and
correct in all respects.
6.)
The investor acknowledges the inherent risk associated with the selected unit trust(s) and agrees that ICEA LION Asset Management
Limited will not be liable for the consequences of market influences and consequent changes in unit prices. The investor bears the
complete investment risk. Neither ICEA LION Asset Management Limited nor the ICEA LION Unit Trust Funds will be responsible for any
7.)
loss, consequential or otherwise, arising from changes in tax or other legislation that may affect the investment returns of the unit
trust(s).

The investor is entitled to any information the law requires a Collective Investment Scheme provider to disclose. ICEA LION Asset
Management Limited is obliged to obtain and transmit such information if the investor requests for it.

8.) Once an account has been opened, a statement of investment will be sent to the investor every month via email. In addition, copies of
statements are available to the investor on request from ICEA LION Asset Management Limited.
ICEA LION Asset Management Limited reserves the right to withhold processing of any unclear, incomplete, or ambiguous instruction
9.) forwarded by the investor.
ICEA LION Asset Management Limited or the ICEA LION Unit Trust Funds will not be liable for any loss incurred due to incorrect
information supplied by the investor.
10.)
Please note that past performance is no indication of future results and that investing in a Unit Trust scheme constitutes a risk to your
invested capital. This document does not constitute a distribution recommending the purchase or sale of any security or portfolio. We
11.)recommend that you consult our Financial Advisors to obtain professional advice before exercising any decisions based on the information
present in this document.
Please be advised that the ICEA LION Unit Trust Funds Information Memorandum contains all information necessary to evaluate our Unit
12.)
Trusts and should be read before investing.

13.)

ICEA LION Centre, Riverside Park Chiromo Road, Westlands Tel: +254 (0) 20 275 0000 | +254 719 071000 | +254 730 151000
P.O. Box 46143 – 00100 Nairobi Contact Centre: +254 719 071999 | +254 730 151999
Email: [email protected] www.icealion.co.ke
 Q)Data Protection

ICEA LION Insurance Holdings Limited (consisting of its subsidiaries: ICEA LION Life Assurance Limited, ICEA LION General Insurance Limited,
ICEA LION Asset Management Limited, ICEA LION Trust Company Limited) (“we”, “us”, “our” or ICEA LION Group), as a data handler is
committed to ensure that your right to privacy is respected by aiming for our compliance with the provisions of the Data Protection Act, 2019 and
other applicable laws. We recognize the need to safeguard your personal data at different stages of your life cycle with us, this we do by adopting
technical and organizational measures that will ensure the security of your personal data.

As part of our compliance process we have provided you with our Group privacy notice which you can find on our website (https://icealion.co.ke/icea-
lion-group-data-privacy-notice). This notice provides you with information regarding how we use your personal data, your rights, how long we retain your
data and other information regarding our processing of your personal data.

By checking “YES” below, I confirm that I have read and understood the information provided above. I acknowledge and consent that ICEA LION Asset
Management Limited will use my personal data to administer and manage my investment account. This may include availing my personal data to our
technology service providers e.g. google, Microsoft etc. (both local and international), as part of the account administration process. Further, if
applicable, I consent to the use of personal data of children provided in this form. This consent can be withdrawn at any time.

• YES NO

ICEA LION Group would like to contact you regarding other products and services from any of our subsidiary companies. By checking “YES” below, you
consent to receiving marketing information about ICEA LION Group’s products and services. You have a right to withdraw or opt out of this form of
communication to you at any time, which withdrawal will not affect our delivery of services to you.

• YES NO

CYRUS MUTURI KAGUIMA

Name................................................................................................... Signature....................................................................
P.O. Box 46143 - 00100 GPO Nairobi, Kenya
Telephone: +254 020 2750 000
Mobile: +254 719 071000 / +254 730 151000 / +254 719 071204
Fax: +254 020 4449978
Email: [email protected]