Contact Details Account

Policy number Date Time

PERSONAL INFORMATION

Name

Surname

Identity number

Address

Postal code

CONTACT DETAILS

Telephone

(Work) Code No. (Home) Code No.

Cellphone number

Email address

Salary reference

PAYMENT INSTRUCTION

Please credit my bank account below with the net amount. Name of bank

Branch code

Name of

account holder

Account number

Account type: Current Savings Transmission

I, the undersigned, request Old Mutual to deposit the proceeds into the bank account provided and declare that the address and bank details provided are complete and accurate. I won’t hold Old Mutual responsible for any risk of liability resulting from the proceeds deposited into the incorrect bank account if I provided the incorrect bank details.

FULL SURRENDER (includes termination of Risk/Funeral Benefits) BENEFIT SURRENDER I would like to cancel the Plan(s) and have the full surrender value, where applicable, paid to me. I am the legal owner of the Plan(s) and I have not ceded nor pledged the Plan(s) by ante-nuptial contract or otherwise. If there is an outstanding Zero Interest Loan this will be settled from the surrender proceeds before they are paid to me. I understand that the surrender process ends the Plan(s) and that the surrender value is the withdrawal of the cash value of the Plan(s). I understand that no further benefits are payable on the Plan(s) after the surrender is processed. I am also aware of and consent to the Surrender charge. Benefit Occurrence Role Old premium Old cover amount New premium New cover amount TOTAL NEW PREMIUM

Policyholder’s signature Date

If you have a 2-IN-ONE SAVINGS PLAN, your Plan consists of a Long and a Short Term Pocket. You will not be able to continue with either Pocket if the other is surrendered. Both Pockets will be surrendered and closed together. The amount quoted by Old Mutual may include premiums paid in advance as well as premiums paid but not cleared with my bank. Because I cannot withdraw from premiums paid in advance and uncleared premiums, the amount that Old Mutual pays into my bank account when they process my transaction, may be less than the amount quoted.

TRANSACTION

REQUEST

1

Craft Transaction Request Form ombds 03.2021 C3024 PART-WITHDRAWAL

Amount OR Maximum

I would like to apply for a Part-Withdrawal on the abovementioned Plan(s). I am the legal owner of the Plan(s) and I have not ceded nor pledged the Plan(s) by antenuptial contract or otherwise. I understand that the Part-Withdrawal will affect my current fund value and the final maturity value of the Plan(s). I am also aware of and give consent to the Part-Withdrawal charge that may apply, where applicable. Policyholder’s signature Date

The amount quoted by Old Mutual may include premiums paid in advance as well as premiums paid but not cleared with my bank. Because I cannot withdraw from premiums paid in advance and uncleared premiums, the amount that Old Mutual pays into my bank account when they process my transaction, may be less than the amount quoted.

ZERO INTEREST LOAN

Amount OR Maximum

I would like to apply for a Zero Interest Loan on the above-mentioned Plan(s). I am the legal owner of the Plan(s) and I have not ceded nor pledged the Plan(s) by antenuptial contract or otherwise. I understand that the amount of any loan taken will be transferred, within the policy, to a Capital Secured Fund. This will ensure that the amount does not lose any value. There will be no growth on the amount in the Capital Secured Fund and no charges will be applicable to money in the Capital Secured Fund, but the money will also not be accessible. I am not expected to repay the loan during the term of the policy, on termination of the policy the loan will be settled from the policy proceeds. If I want to repay the loan, I can contact Old Mutual on 086*-**-**-** for information on how to repay it. I agree that a charge will be deducted from the policy when I take out the loan. Policyholder’s signature Date

The amount quoted by Old Mutual may include premiums paid in advance as well as premiums paid but not cleared with my bank. Because I cannot withdraw from premiums paid in advance and uncleared premiums, the amount that Old Mutual pays into my bank account when they process my transaction, may be less than the amount quoted.

REFUND

The amount quoted by Old Mutual may include premiums paid in advance as well as premiums paid but not cleared with my bank. Because I cannot withdraw from premiums paid in advance and uncleared premiums, the amount that Old Mutual pays into my bank account when they process my transaction, may be less than the amount quoted.

Months Premium x (No of months) =

Months Premium x (No of months) =

Policyholder’s signature Date

2

Craft Transaction Request Form ombds 03.2021 C3024

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