RSA

Existing contract number

NEW ZERO INTEREST LOAN / 1 6 6 6 0 7 4 2

DISINVESTMENT AND PLAN / Investment Plan number/Savings Benefit number

SAVINGS BENEFIT F l e x i n v / 2
CANCELLATION FORM (e.g. COMMITINV/1)

Intermediary code
(MAX INVESTMENTS/INVESTMENT
HORIZONS/GREENLIGHT SAVINGS) 7 0 5 1 7 4
(e.g. PFA: A 123456
Old Mutual Investment Services (Pty) Ltd, registration number 1996/00452/07 (OMIS),
BROKER: 78870)
a licensed Administrative Financial Services Provider.

The submitting party must please fax the completed application form to IMED:
0860 00 46 34 or (High Value: 0860 12 11 33)

This application form has been checked for completeness and accuracy.
Name of Sales Co-ordinator/
Admin. Support person / I ntermediary
Ursula La Vita

Contact details of Sales Co-ordinator / Admin. Support person/Intermediary

Telephone number 021-5910303

Email address ursula@fisherconsulting.co.za

IMPORTANT NOTES
In this document:
• the singular form of a word includes the plural and vice versa;
• any gender includes the other gender;
• references to persons include individuals, juristic persons, partnerships and any other body of persons.

Please complete in BLOCK LETTERS and fax to IMED: 0860 00 46 34 or (High Value: 0860 12 11 33).
1. If a security cession has been recorded in respect of this Plan/ Savings Benefit, your request for zero interest loan, part / f ull disinvestment or Plan/
Savings Benefit cancellation can only be processed if we receive a letter from the Cessionary giving us permission to proceed or informing us that the
cession can be cancelled.

2. ✔ Please attach proof of identity.

3. ✔ Proof of banking details is required (e.g. a cancelled or used cheque).

4. FICA documents (e.g. proof of identity, FICA Addendum, FICA Declaration, utility bill) are required in the event of a loan/disinvestment or Plan/Savings
✔ Benefit cancellation within 3 years of inception of a policy in respect of which the annual total of recurring premiums paid does not exceed R25 000
or a single premium payable does not exceed R50 000.
5. Should the Contracting Party be a company, a Letter of Authority from the entity confirming who may sign on behalf of the entity is required. The letter
must be on a company letterhead of the entity.

6. If the Contracting Party is a trust, a resolution signed by ALL the trustees is required.

7. Failure to comply with the above requirements may, at the discretion of Old Mutual Life Assurance Company (South Africa) Limited or Old Mutual Investment
Services (Pty) Ltd, result in this instruction being rejected, with resultant delays in processing the request.
8. Old Mutual Life Assurance Company (South Africa) Limited /Old Mutual Investment Services (Pty) Ltd reserves the right to retain for a specific period, any
amounts of money that require debit order or stop order clearance until such time that clearance has been obtained.

PLEASE TICK ONE RELEVANT BLOCK FOR REQUESTED TRANSACTION

Zero Interest Loan

DISINVESTMENT:

Part Disinvestment - You will continue paying premiums on your Plan/Savings Benefit

Full Disinvestment - You will continue paying premiums on your Plan/Savings Benefit

✔ Full Disinvestment and Cancellation of Plan / S avings Benefit - You will no longer pay premiums on your Plan/Savings Benefit*
* If the Savings Benefit cancellation is selected, the Savings Benefit premium will be cancelled. The GREENLIGHT Risk Benefit will still continue.

PLEASE TICK THIS BLOCK IF YOU WOULD LIKE THE REQUESTED TRANSACTION
ABOVE TO ONLY BE EFFECTED ONCE YOUR PLAN REACHES MATURITY**.

Maturity Date D D M M Y Y Y Y
** Maturity takes place at the end of your premium paying term. At maturity, your plan will convert to a Flexible Investment Plan.

Old Mutual Life Assurance Company (South Africa) Limited, registration number 1999/004643/06 1 Max/GL/IH Zero Interest Loan App bds 11.2018 L12935.1
 SECTION 1 DETAILS OF CONTRACTING PARTY

Title: Mr Ms ✔ Mrs Other Initials D

Surname/
Name of institution
E s a u
Full names /
Contact person D e b o r a h
Previous surname
(if applicable)
ID number / I nstitution Company
registration number
6 1 1 0 0 9 0 2 1 6 0 8 7 registration date

Passport number (where no South African ID number is available)

Country of issue of
passport

Date of birth D
0 D M M
9 1 0 Y
1 Y
9 Y
6 Y1
Income tax number 1 4 6 9 4 7 6 1 4 5 Are you a South African resident? Yes ✔ No

Residential address
3 U n i e S t r e e t , B e l l v i l l e
S o u t h Postal code 7 5 3 0
Postal address
S a m e A s a b o v e
Postal code

Contact number (Work) Code No.

(Home) Code No.

Fax Code No.

Cellphone number 0 8 1 3 5 4 1 9 1 8

Email address d e b b i e e @ t b h i v c a r e . o r g

SECTION 2 ZERO INTEREST LOAN (LIFE: PURE INVESTMENT ONLY)

• 
I hereby apply to Old Mutual for a Zero Interest Loan. I understand that it is a pre-condition of this loan that I switch an amount equal to the loan amount to
the Capital Secured Fund and,
• 
I hereby instruct Old Mutual to switch an amount equal to the realisable Rand value of the units from the investment fund(s) selected below to the Capital
Secured Fund.

I understand that I will not earn any growth on the funds that are switched to the Capital Secured Fund.

AMOUNT OF LOAN

From: Fund Name Rand amount % of units

Note that the actual rand amount of the loan may not be exactly equal to the amount requested, due to daily fluctuations in the unit price.

Should debit order or stop order in operation be cancelled? YES

(If “Yes” is not selected, we will continue to collect premiums.)

For a Regular Premium Investment Plan/Committed Investment Plan a Plan Amendment Charge/Reduction Fee will be deducted from the fund value. For
a Focussed Investment Plan a reduction fee and Transaction Admin Fee will be deducted from the fund value.

For Flexible Plans (Xtra), a reduction fee will be deducted from the fund value if a Zero Interest Loan is made within the first 5 years of the plan.

LIMITATION OF LOAN AMOUNT

I understand that the amount of the loan may be limited as a result of the Addendum to my Savings Benefit (GREENLIGHT only).

In certain circumstances the regulations promulgated under S54 of the Long-term Insurance Act limit the amount that Old Mutual may loan to you. The loan
amount will therefore be limited to the lesser of:
• The sum applied for; or
• The maximum amount available under the said regulations.

I warrant that:
• My/t he Contracting Party’s estate has not been sequestrated/liquidated; and
• The Plan / S avings Benefit has not been ceded or pledged to anyone.
Existing contract number

1 6 6 6 0 7 4 2

Old Mutual Life Assurance Company (South Africa) Limited, registration number 1999/004643/06 2 Max/GL/IH Zero Interest Loan App bds 11.2018 L12935.1
 LOAN TERMS AND CONDITIONS
PAYMENT OF LOAN AMOUNT
Old Mutual has the right to effect payment of the loan amount in more than one instalment, should debit order or stop order clearance still be required in respect
of any amounts paid by me under the Plan / S avings Benefit.

REPAYMENT OF LOAN
Repayments may be made at any time, without notice, either in full or in instalments, provided that the instalments meet Old Mutual’s minimum instalment
requirements for loan repayments from time to time, except that for Max Investments Flexible Plans (Xtra): Repayments may not be made in the first 5 years
of the Plan. After the initial 5 years, repayments may be made at any time, without notice, whether in full or in instalments, provided that the instalments meet
Old Mutual’s minimum instalment requirements for loan repayments at the time.

All repayments of the loan must be made in South African currency, at Old Mutual’s principal place of business.
The full amount of the loan amount will become due and payable on the first occurring of the following events:
• upon any benefits in terms of the Plan / S avings Benefit becoming due and payable; or
• death or insolvency/ l iquidation of the /a ny one of the Contracting Party/ies; or
• if the value of an investment fund contained in the Plan / S avings Benefit falls below the minimum limit set by Old Mutual from time to time.

Old Mutual shall apply the benefits payable in terms of the Plan/Savings Benefit towards settlement of the loan.
If there is more than one borrower, you will be jointly and severally liable for the repayment of the loan.

AMENDMENT TO TERMS AND CONDITIONS OF PLAN/SAVINGS BENEFIT

I agree to the amendment of the terms and conditions of my Plan / Savings Benefit as follows:
No cession: I undertake not to alienate or pledge the Plan / S avings Benefit until the loan has been repaid in full.

NOTICES
All notices shall be deemed to have been received by you, unless you prove it was not, if it was:
• posted to you at the address recorded for the Contracting Party whose name appears first on Old Mutual’s records in respect of the Plan/Savings Benefit; or
• sent to you by email or fax as elected by you in this application form.

I select as my domicilium citandi et executandi the physical address provided in the Plan/Savings Benefit.

APPLICABLE LAW
This loan agreement will in all respects be governed by and construed in accordance with the laws of South Africa.

SECTION 3 DISINVESTMENT (LIFE PURE INVESTMENT & LISP PURE INVESTMENT ONLY)
APPLICATION FOR A DISINVESTMENT: OLD MUTUAL AND OMIS
3.1 I hereby request a disinvestment, subject to the terms and conditions set out herein. (Place an “X” in the appropriate block.)
3.2 I understand that this disinvestment is subject to the terms of the Addendum to my/our Savings Benefit (Greenlight only).
3.3 I understand that Old Mutual /OMIS reserves the right to undertake any realisation of investments necessary for disinvestment purposes over a period
of up to 30 trading days on the relevant stock exchange(s) and to determine the total disinvestment value by reference to the amounts realised for such
investments over that period. If no Investment Funds are indicated, the total amount or units invested will be proportionally disinvested from all current
Investment Funds. Old Mutual/O MIS is entitled to delay the payment of any disinvestment or the processing of switches if any party holding assets on their
behalf or any of their partners delay payment of the proceeds to them. If a restriction is placed on the sale of assets in the Underlying Investment Fund,
which can happen from time to time, the same restriction will apply to your Underlying Investment Fund. This can significantly delay the processing of
disinvestments or switches.
3.4 For a Regular Premium Investment Plan/Committed Investment Plan a Plan Amendment Charge/ Reduction Fee will be deducted from the fund value. For
a Focussed Investment Plan a reduction fee and Transaction Admin Fee will be deducted from the fund value.

3.5 For a Flexible Plan (Xtra), a reduction fee will be deducted from the fund value if a disinvestment is made within the first 5 years of the plan.

3.6 With a full / p art disinvestment the client continues with the existing premium schedule or ad hoc investments into the plan subject to the following:
• If the value of all Investment Funds contained within the Plan/Savings benefit, less the amount of any outstanding loan debt, falls below the minimum
limit set by Old Mutual from time to time, the Plan / S avings benefit will be cancelled. If this happens no value will be payable under this Plan/Savings
Benefit in respect of the Investment Plan.

OLD MUTUAL INVESTMENT SERVICES (PTY) LTD:

I WARRANT THAT:
3.7 My / t he Contracting Party’s estate has not been sequestrated/liquidated; and
3.8 The Plan / S avings Benefit has not been ceded or pledged to anyone.

I UNDERSTAND THAT:
3.9 The price payable for the units to be repurchased in terms of this request will, under normal circumstances, be the Management Company’s repurchase
price ruling on the business day after the documentation is received by OMIS.
3.10 Repurchase transactions will be subject to the terms and conditions in the relevant Trust Deed(s).
3.11 Should the units tendered for repurchase have been ceded, the written consent of the cessionary must be provided before the repurchase can be processed.
3.12 There are no restrictions on the number of part / f ull disinvestments.
3.13 With a full / p art disinvestment the client continues with the existing premium schedule or ad hoc investments into the plan subject to the following:
•  Plan may be terminated if the value of all the Underlying Investment Funds contained therein falls below the minimum limit set by OMIS from time
A
to time. The Contracting Party shall receive any balance in cash after units have been sold to recover any charges due to OMIS that have not yet been
recovered.

3.14 (Place an “X” in the appropriate block)

(a) Full disinvestment

OR

(b) Part disinvestment (if selected, please complete table below)

Existing contract number

1 6 6 6 0 7 4 2

Old Mutual Life Assurance Company (South Africa) Limited, registration number 1999/004643/06 3 Max/GL/IH Zero Interest Loan App bds 11.2018 L12935.1
 AMOUNT OF LOAN

From: Fund Name Rand amount % of units

Note that the actual rand amount of the disinvestment may not be exactly equal to the amount requested, due to daily fluctuations in the unit price.
* If no funds are indicated, the total amount of units disinvested will be proportionately disinvested from all current funds.

SECTION 4 PLAN / SAVINGS BENEFIT CANCELLATION (LIFE PURE INVESTMENT & LISP PURE INVESTMENT ONLY)
Old Mutual Life Assurance Company (South Africa) Limited
4.1 I hereby request a Plan / S avings Benefit cancellation, subject to the terms and conditions set out herein.
4.2 I understand that this Plan / S avings Benefit cancellation is subject to the terms of the Addendum to my/our Savings Benefit (Greenlight only).
4.3 I understand that Old Mutual reserves the right to undertake any realisation of investments necessary for disinvestment purposes over a period of up to 30
trading days on the relevant stock exchange(s) and to determine the total disinvestment value by reference to the amounts realised for such investments
over that period. If no Investment Funds are indicated, the total amount or units invested will be proportionally disinvested from all current Investment
Funds.
4.4 On a Regular Premium Investment Plan/Committed Investment Plan/Focussed Investment Plan/a Plan Amendment Charge/Reduction Fee/Transaction
Admin Fee will be deducted from the fund value.
4.5 For a Flexible Plan (Xtra), a reduction fee will be deducted from the fund value if the plan is cancelled within the first 5 years.
4.6 Plan / S avings Benefit cancellation results in the Investment Plan/Savings Benefit ceasing.
4.7 If the GREENLIGHT Savings Benefit cancellation is selected, the Savings Benefit premium will be cancelled. The Greenlight Risk Benefit will still
continue.

Old Mutual Investment Services (Pty) Ltd

I WARRANT THAT:
4.8 My / t he Contracting Party’s estate has not been sequestrated/liquidated; and
4.9 The Plan / S avings Benefit has not been ceded or pledged to anyone.

I UNDERSTAND THAT:
4.10 The price payable for the units to be repurchased in terms of this request will, under normal circumstances, be the Management Company’s repurchase
price ruling on the business day after the documentation is received by OMIS.
4.11 Repurchase transactions will be subject to the terms and conditions in the relevant Trust Deed(s).
4.12 Should the units tendered for repurchase have been ceded, the written consent of the cessionary must be provided before the repurchase can be processed.
4.13 On a Committed Investment Plan/Focussed Investment Plan/a Plan Amendment Charge/Reduction Fee/Transaction Admin Fee will be deducted from
the fund value. a Reduction Fee will be deducted from the Fund Value.
4.14 Plan / S avings Benefit cancellation results in the Investment Plan/Savings Benefit ceasing.

SECTION 5 PAYMENT DETAILS

Please credit my / o ur bank account below with the net amount.

NB: Payments will not be made into offshore bank accounts or to third parties.

Name of bank A B S A
Branch name B e l l v i l l e S o u t h Branch code 6 3 2 0 0 5
Name of
account holder
D L A E s u a

Account number 4 0 6 2 9 0 8 8 1 2

Account type: ✔ Current Savings Transmission

SECTION 6 COMMUNICATION
I hereby instruct Old Mutual Life Assurance Company (South Africa) Limited/Old Mutual Investment Services (Pty) Ltd to send me, the Contracting Party,
confirmation of the actual values available via the communication medium indicated by myself below. Email will be used as the preferred medium of
communication if email and fax details are provided. Postage is not an option.

✔ Email d e b b i e e @ t b h i v c a r e . o r g
OR

Fax Code No.

Existing contract number

1 6 6 6 0 7 4 2

Old Mutual Life Assurance Company (South Africa) Limited, registration number 1999/004643/06 4 Max/GL/IH Zero Interest Loan App bds 11.2018 L12935.1
 SECTION 7 DECLARATIONS
Financial Advisory and Intermediary Services Act
• It is my responsibility to ensure that this form is fully completed and accurate before I sign it
• I will on request be provided with a copy or a printed record of this transaction within a reasonable time.

Tax
Disinvestments from certain second-hand policies are subject to Capital Gains Tax.

Long-term Insurance Act

The law currently restricts Old Mutual from paying Benefits to you within certain periods.

This means you may only make one loan and one disinvestment:
• during the first five (5) years of the Plan, and also
• for a period of five (5) years starting from the first day of the month that you pay a premium
– that by itself exceeds, or
– if added to the other premiums already paid and still to be paid in that year exceeds, or
– if it is the first of recurrent premiums which if paid at that rate for the whole year will cause the total value of the premium to exceed the premiums you paid
in one of the two years by more than 20%.

Financial Intelligence Centre Act

I understand that:
• My banking details will need to be verified by my bank and Old Mutual has the right to request such account confirmation in writing, and in addition, for
amounts over R50 000 Old Mutual may confirm the details with me telephonically.
• The transaction will only be processed once Old Mutual has received the confirmation as required.

PROTECTION OF PERSONAL INFORMATION ACT (POPIA) NOTICE

The Old Mutual Group would like to offer you ongoing financial services and may use your personal information to provide you with information about products
or services that may be suitable to meet your financial needs. Please SMS your ID number to 30994 if you would prefer not to receive such information and/or
financial services.

We may use your information or obtain information about you for the following purposes:
• Underwriting
• Assessment and processing of claims
• Credit searches and/ o r verification of personal information
• Claims checks (ASISA Life and Claims Register)
• Tracing beneficiaries
• Fraud prevention and detection
• Market research and statistical analysis
• Audit and record keeping purposes
• Compliance with legal and regulatory requirements
• Verifying your identity
• Sharing information with service providers we engage to process such information on our behalf or who render services to us. These service providers may be
abroad, but we will not share your information with them unless we are satisfied that they have adequate security measures in place to protect your personal
information.

You may access your personal information that we hold and may also request us to correct any errors or to delete this information. In certain cases you have the
right to object to the processing of your personal information.

You also have the right to complain to the Information Regulator, whose contact details are:
Website www.justice.gov.za/inforeg/index.html
Contact number 012 406 4818
Fax 0865 00 33 51
Email inforeg@justice.gov.za

To view our full privacy notice and to exercise your preferences, please visit our website on www.oldmutual.co.za

I confirm that I have read this declaration as well as the loan/disinvestment terms and conditions and I understand the content and implications thereof.

I am aware that a Reduction Fee / P lan Amendment Charge and a Transaction Admin Fee (if applicable) may be levied in terms of the Plan/Savings Benefit
in the event of a loan or disinvestment.

For a Flexible Plan (Xtra), a reduction fee will be deducted from the fund value if a disinvestment is made within the first 5 years of the plan.

I declare that I have full power /a uthority to apply for and enter into this transaction.

Signed at (place) on (date)

Signature of contracting party/authorised person Signature of Legal guardian

Existing contract number

1 6 6 6 0 7 4 2

Old Mutual Life Assurance Company (South Africa) Limited, registration number 1999/004643/06 5 Max/GL/IH Zero Interest Loan App bds 11.2018 L12935.1
 SECTION 8 IDENTIFICATION
(This identification is called for by Old Mutual/OMIS and is a precaution to safeguard the interests of the Contracting Party(ies) and must be completed by a
Commissioner of Oaths or an Old Mutual /O MIS administrative officer or Old Mutual financial adviser or Old Mutual contracted broker. For clients outside the
Republic of South Africa, identification is to be completed by a Justice of the Peace, solicitor or local police.)

The Contracting Party(ies) / Authorised Person whose signature(s) I witnessed, was/were identified by production of

ID number 6 1 1 0 0 9 0 2 1 6 0 8 7

Signed at (place) Goodwood on (date)

Full names in print of person who identifies Lionel G Fisher

Signature of person who identifies

Official stamp
of signatory
Designation Financial Advisor

Existing contract number

Old Mutual is a Licensed Financial Services Provider 1 6 6 6 0 7 4 2

Old Mutual Life Assurance Company (South Africa) Limited, registration number 1999/004643/06 6 Max/GL/IH Zero Interest Loan App bds 11.2018 L12935.1