Policy Discharge

Fairbairn House, PO Box 121, Rohais, St. Peter Port, Guernsey, GY1 3HE, Channel Islands
Tel +44 (0)1481 726726, Fax +44 (0)1481 728953, www.oldmutualinternational.com

To be completed in the event of the death of the sole/remaining life assured

Policy Number(s)

Name of the Life Assured in question

It is hereby acknowledged that the total amount payable shown above is the amount payable in respect of the above
mentioned policy (plus any interest accrued) and payment to the payee of the amount will represent full and final settlement of
all monies due under the said policy/policies.

Payment will be made electronically direct to a specific bank.

Payment currency

Bank Name

Bank Address

Sort/SWIFT/ABA

Account holder name

Account number

Ref to be quoted

Sub account details

Comments

Routing details

Correspondant bank

Account number

Sort/SWIFT/ABA

Comments

Please continue overleaf

Policy Discharge (continued)

If payment is being made to a third party, the claimant(s) hereby undertakes to indemnify Old Mutual Guernsey from and
against all claims and demands and against all losses, damages, expenses and charges which it may sustain, incur or be
liable to in respect of, arising from or in connection with the making of the said payment.

Name of First Claimant (block capital please)

Signature of First Claimant

Name of Second Claimant (block capital please)

Signature of Second Claimant

Name and occupation of Witness

Address of Witness

Signature of Witness Date

NB. A Claimant’s spouse may not witness this Discharge.

B-1323 (1201)