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REQUEST FORM
FOR GREENLIGHT COVER REVIVALS
AND/OR INVESTMENT HORIZONS/MAX
Old Mutual Life Assurance Company (South Africa) Limited, registration number 1999/004643/06
Old Mutual Investment Services (Pty) Ltd, registration number 1996/00452/07 (OMIS) INVESTMENTS REINSTATEMENTS
The submitting party must please email this request with the contract number in the subject line to
CustomerRetentionUnitRevivals@oldmutual.com
IMPORTANT NOTES
1. Please submit one request form per contracting party. Additional request forms must be submitted for additional contracting parties.
2. If an adviser change is required as part of this revival/reinstatement request, please attached a completed IAN document. No adviser change will
be processed once the revival/reinstatement has been finalised.
3. Customer Retention Unit will attempt to contact the customer within 72 hours and keep the financial adviser updated via e-mail of each
attempt to contact customer.
Please tick the confirmation blocks. This request will not be acted on if blocks are not ticked.
1. Confirm if customer does in fact qualify for cover revival and/or reinstatement.
2. Confirm if the customer does qualify for cover-revival and/or reinstatement as per product rules, please contact the customer
and find out if they are willing to revive/reinstate the paid-up policy(ies).
3. If YES, please complete the information related to the contracting party and the contact numbers below.
Title: Mr Ms Mrs Other Initials
Surname
Cellphone
Contract number(s)
1. 2. 3.
Benefit(s)/Plan(s)
1. 1. 1.
2. 2. 2.
3. 3. 3.
4. 4. 4.
5. 5. 5.
4. Is the contracting party willing to pay in the arrear/missed premiums on the Max Investments and/or Investment YES NO ✔
Horizons plans and/or Greenlight savings benefit?
IMPORTANT NOTE
According to certain product rules. plans may only be reinstated if the arrears/missed premiums are paid. Please inform
your customer of these mandatory premiums.
AUGUST 2017 1 Greenlight Cover Revival & MAX Investment Reinstatements Form bds 08.2017 L11048