rr L Q OLDMUTUAL RSA NEW ZERO INTEREST LOAN/ DISINVESTMENT AND PLAN/ SAVINGS BENEFIT CANCELLATION FORM (eg. conmarrinev) Intermediary code (MAX INVESTMENTS/INVESTMENT — . a HORIZONS/GREENLIGHT SAVINGS) (ais) bla is) tral mn arn etn mor REOAEDT OSL * roxer Taro) ‘The submitting party must please fax the completed application form to IMED: (0860004634 or (High Value: 0860721133) ‘This aplication form hae been checked for completeness and accuracy. tare Soe ceranatod : ‘amin Seppo preon/ntemedian [JOhAR Krogh Contact etal of Sales Co-orinator/Admin, Support paronintrmediary ‘Telephone number (01: Emailediress _|ktogh2@okdmutual.com IMPORTANT NOTES Inthis document: singular form ofa word inchides the plural and vce eres + any gender includes the other gender, + reforoncesto persons include indviduatsjuritic persons partnerships and any ther body of persons. Pease complete In BLOCK LETTERS ane fax to IMED: 0880 00 6 34 or High Value 0860127138, 1] a security cession hs been reordein respect of this lan/Saings Beno your request for 20 Interest oan, part/flasnestment or Plan! |__| Savings Benefit cancellation can only be processed fwe receive alter ram the Cassonary giving us permission to proceed or Informig that te cession canbe cancalled Please attach profof identi, Proof o banking deta is required (eg. canceled or used cheque 4 ica documents (eg prt of sent. FIC Addendum, FCA Declaration, uty bl ae required the event of lenfsimvesiment or PlaniSavngs Benefit eanclation within years of inception ofa poy in respect of vnich the annual otal ef recuting premiums pela oes ne exceed R2S 000 ‘orange premium payabe doesnot excvee R50 000, 5. [>] Should the Contacting Paty bea compara eter of Author fam the enti confirming who may sign on behalf ofthe entity is equied The eter rmustbe ona comneary letterhead ofthe ently. 6 ‘the Contacting Panty sa ust resolution signed by ALL the trustees is eared 7. allure to comply with the above requirements may, tthe dsreton of Od Mutual Life Assurance Company (South Ais Lied or Od Mutua investment ‘Seres (By Ls rest in he ineretion boing elected, with resultant delays n processing the fequest, 8. old Wurual tie Assurance Company (South Aa] Liited/Old Mutual Investment Services (Py Ltd reser the ight to retain or ¢ specific pti, ary armounts of money that require debi order ston eter clearance unt sich time tha lesan has beers obtained PLEASE TICK ONE RELEVANT BLOCK FOR REQUESTED TRANSACTION |] zerotnteret Loan DISINVESTMENT: Part Disinvestment - You wll continue paying premiums onyour Plan/Savings Benefit Disinvestment and Cancellation of Plan/Savings Benefit - You wil io longer pay premiums on your Plan/Savings Benet? “ifthe Savings Benet cancoltion is selected the Savings Bene premium wil be canceled, The CREENLIGHT Risk Benaft wl sil continue, PLEASE TICK THIS BLOCK IF YOU WOULD LIKE THE REQUESTED TRANSACTION ABOVE TO ONLY BE EFFECTED ONCE YOUR PLAN REACHES MATURITY" ~ Maturity tees place atthe end of your premium paying term. At maturity your plan Wl coer 08 Fexble Investment Blan- ‘SECTION DETAILS OF CONTRACTING PARTY Tite wots [| Name of nsiation ‘Contact petson Previous suename lfappiesbie) company regictration dat Passport number ‘where no South Nea 1D number i avaliable) coun oft ot I I TELT I SECTION 2 ZERO INTEREST LOAN (LIFE: PURE INVESTMENT ONLY) + hereby appy to Old Mutual ora Zero Interest Lash. understand that tsa pre-condition of thi ean that sertch an amount equal othe loan amount to ‘the Capital Secured Fund and + nereby instruct ld Mutual to switch an amount equ tothe realssble Ran value of he units far the investment ful selected below te the Capital ‘Secured Fond. ‘understand that wil net earn any growth onthe funds tht are switched tothe Capital Secured Fund, "Note that the actual and amount ofthe loan may not be exactly equal tothe amount requested due to daily flictuation inthe unit pce. Should debit order or top order in operation be cancelled? ("Yes" isnot selected, we will continue tocallect premiums) vel) Fora Regular Premium investment Plan/Committed investment Plan a Plan Amendment Charge/Reduction Fee wil be deducted from the fund value, For _ Focursed Investment Plan a reduction fee and Transaction Admin ee willbe deducted from he fund value ‘For Flexible Pans (xtra). a reduction fee will be deducted from the fund value lf Zero Interest Loan is made within the fist yearsof the plan. LIMITATION OF LOAN AMOUNT understand thatthe amount af the loan maybe limite 2 result the Addendum to my Savings Benet (GREENLICHT ony In contain circumstances te regulations promulgated under S54 of the Long term Insurance Act limit the amount that Old Mutual may fan to yeu The loan amount wil therefore be limited tothe laze 2 te sum applied for or ‘+The maximum amount salable unde the sad regulations wacantehat + "Mylthe Contacting Party extate has not beso saquestetediauiated and + The Plan/Savings Benet es not been ceed or pledged to anyone LLOAN TERMS AND CONDITIONS PAYMENT OF LOAN AMOUNT. (Old Wutual hasthe right effect payment oftheloan ameuntin more than eneinstalment. should debit order or stop ore clearance stil bo requredin respect of ary amounts pid by me uncer the Plan/Savings Benefit, REPAYMENTOFLOAN Repayments may be mace at any time without tice the in al orin instalments, provide thatthe Inetalments meet Old Mutual's minimum instalment requirements for loan repayments from time to tim. except that for Max investments Flexible Plan xtra: Repayments may not be made nthe fst years ‘ofthe Banter the initial Spears repayments may be made at any ime wilneut notes whether in ful rninstlments provided that se lnsaiments mest (id Mutua minimum instalment requterentsforloan repayment at the ine ‘Al repayments ofthe loan must be made in South ican currency, st Old Mutuals principal place of business The fll amount eft ean amount wil become due and payee on te fis occuring of the flowing events + upon any beneftsin terms ofthe Pan/Saungs Benet becaming due and payable or + death orinsalveny/iguldstionofthe/any one ofthe Contracting Partyfes or + ifthe value ofan iesttent tnd contained isthe Pan/Sauings Bane falls low the minimum mit set by Old Mutual om time tine ‘oe utual snl apply the benaite payable in tome of the Plan/Savings Benefit tawverds settlement of thea. there i mar than ene Berner you wil be ant and several abe for the repayment othe loan ‘AMENDMENT TO TERMS AND CONDITIONS OF PLAN/SAVINGS BENEFIT {agree tothe amendment ofthe terms and coitons of my Plan/savings Benet 2 lows: "Nocestion:|undortake net to alienate pledge the Pan/ Savings Bene unt hel has bes repaid fl Novices ‘notices shal be deem! to have been received by you unezs you prove twas nok its. ‘posted to you at the address recorded forthe Contracting Party whose neme aapear ret on Old Mutua record In regneet of the Plan/Soungs Benefit oF 1 Sento yu by ema ar fax a elctec by ou In tis apieaion frm Isolect as ry domelum citana et executana the physical acdess provided in the PanSavings Bore. APPLICABLE LAW Thsloan agreement win all espects be goveined by and consted in accordance with the avs of South Mice ‘SECTION 5 DISINVESTMENT (LIFE PURE INVESTMENT & LISP PURE INVESTMENT ONLY) APPLICATION FOR A DISINVESTMENT: OLD MUTUAL AND OMIS. 31 thereby ecuest a sinvestment subject to the tems anelconaions et cut her. (Pace an "Xin the appropiate block) [32 Tunderstan that this dsiestment i subject othe tems of he Addendum to my/our Savings Benefit Creeiight ony 153. Lunderstand that Old Mutual/OMIS reserves the ight to undertake any ealission of investments nacesary for dsinvertment purposes aver prod ‘of up to 0 trading dys on the relevant stocxonchangels) and to determine te total csivestrent valve By reference tothe amounts reaie! for seh Investments over that pied ho Investment Funds re incieated, the total rnount runs vest wil be proportional dsiwested fom al ument lnestrent Funds Old Mutua /OMIS I ened to delay the payment oF any disinvestment or the procesing ofzutenesitary party holding set on that ‘half or any of her partrers delay payment ofthe proceeds to them. Ia retieton i placed onthe sale of eet inthe Underyng nmestment Fund, lie ean happen rom time fo ime, the same restriction wil apply to your Undering investment Fund This ean sgnfcantiy delay the processing of 54 Fora Regular Premium investment PankCommsted investment Pana Plan Amendment charge/Redition Fee wil be deducted fom the fund value For 8 Focussedinvestment Plan a reduction fe and Traneacton admin Fee wil be deducted from tho fund vel, 55. Fora Flenbe Plan Xx reduction foe will be deducted fem the fund value fs csinvestment mace within the ist years ofthe plan, ‘36 With ful/parcsivestment the cent continues with he sting premium schedule or aa hoc ivertments|nto the plan subject to the folowing + thesalue fal evastment Funds contained vthin te Pan/Sevngs benef les the amount of any outstanding lean det fl below the nim limit set by Old Mutua rm time to time. the Pian/Savings beret wil be canelled If Uns happens novalue wl be payable uncer ti Plan/Savings Benefit in respect ofthe Investment Plan ‘OLD MUTUAL INVESTMENT SERVICES (PTV) LTD: 137. wy/tne Contracting Party estate has not been sequestatediqudated nc 3B. The Pan/Savings Benefit has net been ceded or pledged to anyone, 59. The pice payable for he units tobe repurchase in terms ofthis request wl under normal ckeumetances be the Management Company's repurchese ice ruling onthe busines ly after the documentations ceed by OMS, 510 Repurchase tansactions wl be subject tothe tems and condition inthe relevant Tast Deed '51)Shouldthe units tendered for repurchase have been ceded, the wlten content of ta cezsonary must be prada before the repurchase can be processed S512. Thare are ne reertions on the numberof itl esinvestments 515. With ful/partlcinvestment the client continues withthe ensting premium schedule er adhoc investments into the plan sublet to the ftewing: + Alan may be terminatd ifthe value ofl the Undervng Investment Funds contained therein falls below the minimum ini se by OMIS fom tne to time: The Cortrating Party shall ecive ary belance in cash ater units have been sod to recover ay charges cu to OMS that have not ye been 5% (Place an-2" in the appropriate bloc) (a) | | Fuletcinvestment (01) | Partdisinvestment if selected lense complete table below) ‘isting contrat numberFrome Fund Name Rand amount ‘eofunits Note that the actual rand amount of the disinvestment may not be exact equal tothe amount requertd, duet dally fluctuation inthe uni rice, “tf funds are indicated, the total amount of unit diinvested wl be proportionately caivested fom al curren fund SECTION 6 PLAN/SAVINGS BENEFIT CANCELLATION (LIFE PURE INVESTMENT & LISP PURE INVESTMENT ONLY) ‘Old Mutual Life Assurance Company (South Africa) Limited 41 Ihoreby request a Plon/Savings Benefit cancelation subject ta the terms al canaltions stout herein, 42 lunderstana thatthe Plan Savings Benoit cancllaton Ie subjtc othe terms of the Addensum to my/our Sevings Benet (Gren oni 43. lundetstand that Old Mutua reeves the right to undertake any realiaton of investments necessary or disinvestment purposes ver «period of upto 30 trang days onthe relovat stock exchanges and to determine the total clsivestment value by relerance to the amounts else for sve twest nes ‘over that period fn imestment Funds ae inated the total ammount or Unt invested wal be proportional lerwested ftom all current Ivestrnent 464 Ona Regular Premium imestment Plan /Commited Investment PlaryFecussed investment Plan/a Pn Amendment Charge/Reclution Fee/ Transaction ‘Admin Fee willbe deducted from the fund value AS Fora FesbiePlen (tra. a reduction fe wil be deucte fom the fund value the pan is canceled within the ist $ years. AS _Plan/Sevings Boneftcancelaon results inthe Investment Plan/Sevings Benefit cessing ‘47 the GREENLIGHT Savings Benefit cancallation Is selected, the Savings Benefit premium wil be cancelled. The Greenlight Risk Benefit wil til continue ‘Old Mutuat investment Services (Pty) Ltd 48. Mylthe Contacting Pary/s estate has not been sequestratadiquidated and 49. The Plan/SavingsBenefchas not been ceded o pledged to anyone 110 The price payable forthe units to be repurchase In tvs ofthis tequest wll under normal circumstances be the Management Company's repurchase ice ruling on the busines dey after the documentation received by OMS, “411 Repurchase transection wl be subject tothe terms and condition inthe eevant Tastee ‘£12 Should ho units tendered forrepurchase have been cade, he writtanconeent ofthe cesiony must be provided before the repurchase canbe processed 4415. On a Committed insstmenePlanFacussed Imestrent Plan/a Plan Amendment Charge/Reduction Fe/Transaction Admin Fe wil be deducted from fund valve. @ Reduction Fe wil be delucted fom the Fund Value ‘414 Plan/Savings Benet cancaliaton esltsin the Investment Pian/Saungs Bane ceasing, SECTION 5 PAYMENT DETAILS ‘lease creat my/our bank account balon ‘SECTION 6 COMMUNICATION \ereby instruct Olé Mutual Ufe Assurance Company (South Aca LimitedjOld Mutual Investment Services (Py) Ltd to send me the Contacting Paty confirmation ofthe actual values available a the communication medium indicated by myself below” ral wil be used as the preferred medium af communication femal and fx deta are provided. Portage isnot an option. | ems T LLL I T Fae ode I Ne ‘isting contract number L — |- L SECTION7 DECLARATIONS Financlal Advisory and intermediary Services Act + Tesi tesponsbiy to ensure that thie form uly completed and accurate before aig + lon request be provided witha copy printed ecard of this Wansacton within reasonable tne Disievestment hm certain second-hand polices are subject to pital Cain Tax Long-term Insurance Act ‘The lot currently restricts Ole Mutual rom paying Benefits to you within certain peti + during the fit fve (5) years ofthe Pian ancl also + fora period af ve 5] yar starting rom the Fist day ofthe month that you pay 9 premam ~ tasty uaf eceeds oF ~ faded the other premiums stescy paid and sill o be palin that year exceeds or + fitisthe fist of recurrent premiums which pad et tet rat or the whole year vl cause thetotalvalue ofthe premium to exceed the premiums you paid in ane the two years by more than 20% Financial ntl + My banking detas wil nse tobe verified by my bank and Old Mutual has the rght to request such account confirmation in wing. and in elton for amounts over R50 000 Old Mutual may cori the desis with me etephonical + Thetraneation vil ony be processed once Old Mutusl has eceves the confeetion 2 eared nea Contre Act PROTECTION OF PERSONAL INFORMATION ACT (POPIA) NOTICE ‘The Ola Mutua! Group would tke to offer you ongoing Francia services ane may Ute your personal information to provide you with information about products ‘orservces that may Be suitable to meet your financial Reeas Pease SWS your ID number to $0994 you WOU prefer not to recive such information and/or ‘nancial services ‘We may use yurinformation or obtain information abot ou forthe flowing purposes *Underarleng 1 astestrent end processing of lsims 1 Gree searches ander vertfeation f personal information {Clams checks ASISA ite ena Cisims Reser 1 acing beneflanes 1 Matt resaren and ential anal + Compliance with egal and regulatory requirements venting your laentty {Sharing Inormation with saves providers we engage to process ch information on our behalf or who rend sarices tous. Thee service providers may be abroad, out we wil not share you information sith them unless we are satsied that thay have adequate security messuresin place to protect your persona ‘You may acess your personal formation that we hold anl may luo request us to corect any eros ort delat this information In certain cases you have the Fight to objet to the procesing of jour personal information| ‘You also have the right to complain to the Information Regulater, whose contact deta are ‘webste “worsen govzainforegindex hr Fae (0865 00 3551 Em Inforeg@usticegovz0 To ew our ful privacy notice and to exetise your preferences pee Vt ur website on wawwolsmul 2023 J confem that have red this declaration as well as the loan/isinestment terms and conditions and |undersand the content and implications there ‘tam aware that a Reductlon Fee/Plan Amendment Charge and a Transaction Admin Feet applicable) may be levied In erm of th Inthe event ofa loan or disinvestment. an /Savings Benefit Fora Flexible Plan (Xtra. areduction fee willbe deducted from the fund value if disinvestment is made within the fist S years ofthe plan. {actor that have full power/authorlty te apply for and enter into thistransaction. (SSRIRTBIED Johannesburg ent Sea 2urnoed person Signature of Lego querdion“d SECTION IDENTIFICATION (his ereteaton cle for by Ot MitOM and isa precaution to staged the interes ofthe Corracing Pars and must be completed by © Caisone fats or an OL Mita /OMS aru scr Oe eu thancal seo Mute contd roe For clans oe he epic of Sth Aen ceteton tobe completed ya cof te Peace oltre pes) ‘he cantacin Pare utr Peas whots ar wnt waver ated by predton ot Tonumber CT TT TTT ttt Signed tptcel(Johannesburg furore nt enone een oars Krogh “Slonature o person who dentifes L orton QB ocpmutuat ting contract umber enema TET 7