RSA

CUSTOMER CONSENT TO
OBTAIN INFORMATION
CUSTOMER DETAILS

First name(s)

Surname

ID number Date of birth

Address

Postal code

Telephone number Telephone number

(Work) (Home)

Cellphone number

Email address

Is the request on behalf of the customer YES NO

If Yes, please provide:

Relationship

Full name

ID number

I acknowledge that:
1. Appropriate financial advice can only be given after full and proper disclosure of relevant personal and private information about me/us.

2. Such information is required to:

• determine my/our financial situation, financial product experience and financial needs and objectives;
• acquire, maintain and service any financial product or to give related advice.

3. Such information may include any information relating to, or interest in:
• long-term insurance;
• collective investment schemes;
• pension funds;
• any other financial product or service;

4. M
 y/our interests will be best served for the stated purpose if such information is provided by The Financial Services Exchange (Pty) Ltd, trading as Astute, or any
other institution providing a mechanism for the transmission of such information, or

I/we herewith give consent to any authorised financial services provider to release the aforementioned information whether through Astute, or directly, to the
authorised user(s) below:

Authorised user Johannes Krogh Sales code A 1 3 6 8 5

Authorised user Aneske Esterhuizen Staff code F S 0 1 0 9 4

Authorised user Samantha Nthabiseng Staff code F S 3 7 8 8 7

Authorised user Muriel Els Staff code F S 0 0 2 7 2

Authorised user Hermien A Van Loggerenberg Staff code F S 0 2 7 9 1

Authorised user Justine Krogh Staff code A 6 6 6 8 3 3

Authorised user Aaleya Solomons Staff code F S 3 7 8 8 8

Authorised user Jerilee Nortman Staff code F S 4 8 8 5 2

Authorised user Veronica Oratile Matalapeng Staff code

Authorised user Staff code

Authorised user Staff code

Authorised user Staff code

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06. 1 Customer Consent to obtain information ombds 08.2021 C4133
 Authorised user Staff code

Authorised user Staff code

Adviser OLD MUTUAL LIFE ASSURANCE COMPANY (SOUTH AFRICA) LTD FSP number 703

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/or 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 086 500 3351
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/we have products with: (please tick (✓) the appropriate block )

ABSA Altrisk Capital Alliance Discovery Life

Liberty Active Liberty Life Metropolitan Momentum

Nedbank Old Mutual PPS Sanlam

Stanlib Other All of the above

I/we confirm that:

• The authorised user(s) will be acting on my/our behalf.
• I/we hereby waive any right to privacy only for the stated purpose.
• All information must be treated as confidential by the authorised user(s) and adviser and may not be made public without my/our written consent.

This consent is only valid for 12 months from the effective date.

Signed at (place) on (date)

Signature of customer

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 is a licensed FSP and Life Insurer. 2 Customer Consent to obtain information ombds 08.2021 C4133