DETAILS OF LEGAL OWNER

Please print in block letters using black or blue ink. Policy number:

First name(s):
Surname:
Date of birth:

(dd mm yyyy)

CONDITIONS, DECLARATIONS AND RESTRICTIONS (Please tick the applicable block.)

1. I wish to apply for payment of:

(a) / A part-surrender value of R / , thereby reducing a portion of the sum assured and bonuses.
(b) / A surrender value estimated at R / and any additional payment that may be realised on the sale of the policy, subject to the provisions set out in terms of 5 below.

2. I have considered the above options (as well as the option of selling the policy myself on the open market) and I understand the implications of a part surrender or a full surrender value and acknowledge that it may not be in my best interest to terminate the policy in part or in full, or transfer ownership thereof. Payment of the said amount(s) will only be effected on receipt by Old Mutual of all required documentation and shall represent the full and final discharge of Old Mutual’s liability.

3. I declare that:

(a) I am the legal owner of the abovementioned policy,

(b) my estate has not been sequestrated and is at present solvent,

(c) I have not ceded or pledged the said policy to anyone, either by antenuptial contract or otherwise, other than Old Mutual,

(d) there is no other impediment to the option requested in 1 above.

4. I acknowledge that in terms of section 54 of the Long-term Insurance Act of 1998 and the regulations thereunder, only one part or full surrender and one loan can be effected

in the first five years of the policy term or during a restriction period. (Excluding Guaranteed Capital Fund ad hoc withdrawals.)

5. I acknowledge that I am aware of the following:

(a) a Statement of Intent was signed during December 2005 between the Minister of Finance and the long-term insurance industry with regard tominimum standards to be applied in respect of policy benefits, which, if implemented, will mean that the surrender values of certain policies will be enhanced;

(b) in surrendering/part surrendering the policy prior to implementation of the Statement of Intent, I may be losing out on an enhanced surrender/partsurrender value.

6. Resale Option

6.1 I hereby irrevocably authorise Old Mutual:

(a) if the policy is deemed by Old Mutual to be saleable, to advertise my policy on its website for a period of time within its discretion from date of signature and receipt hereof, to disclose any information in respect of the said policy Old Mutual may deem fit to facilitate the sale of the policy and if sold, to transfer my rights, title and interest in and to the policy to the purchaser; and

(b) if the policy is sold for a purchase price (which shall include provision for settlement of any loans, premium debt or similar encumbrance/charge on the policy) which in Old Mutual’s discretion is sufficiently in excess of the surrender value, to set off the surrender value advance, together with an administration fee of 10% (subject to a minimum determined by Old Mutual from time to time; R500 at May 2000) of the said excess, prior to effecting payment of the balance of the purchase price to me in the manner indicated herein; or

(c) if the policy is not so sold, to set off the surrender value of the policy against the advance, thereby terminating the policy.

6.2 I acknowledge that although the full surrender of my policy will be suspended for a period of time, any cover and all benefits which I enjoyed in terms of the policy shall lapse upon payment of the surrender value advance. I further acknowledge that resale is not in any way guaranteed, but is only potential as not all policies have a resale market and is subject to Old Mutual’s specific sale process and the forces of supply and demand.

Is the policy or a portion thereof being replaced by another insurer? / YES / NO / If “YES”, state name of insurer:
Signed at / this / day of / 2007

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Signature of Legal Owner

Capacity / LEGAL OWNER

(State representative capacity if applicable and attach proof of authorisation)

Security Cessionary

Who warrants that he/she is authorised to act on behalf of the security cessionary as well as the legal owner/s where such owner has not signed this document.

Signature of Spouse (if married in Community of Property on or after 01/11/1984)

Assisted by Guardian

Reversionary Signature

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IDENTIFICATION

(This identification is called for by Old Mutual and is a precaution to safeguard the interests of the legal owner and must be completed by an Old Mutual officer or Old Mutual financial adviser or Old Mutual contracted broker or official of an institution which holds a valid cession on this particular policy contract. For clients outside the Republic of South Africa, identification to be completed by a Justice of the Peace, Solicitor or local police.)

The legal owner whose signature I witnessed, was identified by production of ID no.:
Full names of person who identifies:

I understand that I could be held liable for any financial loss resulting from false/wrong identification of the client.

Signed at / this / day of / 2007

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Official stamp of signatory

Signature of the person who identifies

Designation:
Broker Code:

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PAYMENT INSTRUCTION (Please select payment option(s)).
Policy Number
The amounts below must be deducted from the proceeds of the policy and
be paid to Old Mutual investments as indicated below.
Contract number(s): / Amount(s): / Description:
√ / Please credit the bank account below with the nett amount:
Bank name: / Branch name:
Account number / Branch code:
Type of account: / Savings / Current / Transmission
Name of account holder:
CONTACT DETAILS OF LEGAL OWNER
Residential address:
Postal code:
Postal address:
Postal code:
Telephone number(s): (H) / ( ) / (W)
(Cell)
E-mail address:

I confirm that the correct details are reflected above.

Signature of Legal Owner

FOR OFFICE USE:

If the full surrender value is selected, all documentation including the surrender form and policy document must be sent to Policy Files, Mutualpark, after completion of the surrender advance payment to the client.

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