Q Sanilam fe Insurance MEMBER DETAILS «KyQ (This form has tobe filled by Group Member) | hereby designate the following to the beneficiary(ies) to the company provided insurance benefits. I understand that I have designated the primary beneticiary(ies) to receive the proceeds of the insurance the event that I die. I have designated the secondary beneficiary (ies) to receive the benefit only if the primary beneficiary(ies) is deceased at the time of my death, | understand if | have named more than one primary or Secondary beneficiary, those surviving at the time of my death that are not nominated to receive benefits shall share equally in the insurance proceeds, unless | have designated otherwise under “Share %” below. Afier receipt of this form, the designation will relate back to and take effect from the date | sign this declaration, This designation revokes any previous and I reserve the right to change the beneficiary at any time by notifying the company in writing. | understand and acknowledge that this designation may not be upheld in the absence of a Will in Which the gift of the proceeds of the insurances is bestowed upon the same persons in the same shares as designated hereunder1. GROUP LIFE INSURANCE, Legal Name of Passport Number/ID) | Contact Relationship % Share Beneficiary Voter Identity Card | Phone (e.g. spouse, Number child) rimary Beneficiary Secondary Benefici I “If you have named more than one beneficiary, please ensure that the total share % add up to 100%. Please complete all information in English ***Please note that the company shall not be held fiable for any incomplete or incorrect information contained on the beneficiary designation form, Please note that the choice of beneficiaries that you have named above may be subject to the overriding discretion of the trustee, or a Court of Law and the company shall not be held liable for any dispute arising from the exercise of such discretion. Signature of Insured: Muryeg a « Signature of Witness: Sha tee Name of Witness: Passport/ID Number of the Witness: Date: PLEASE SUBMIT THIS FORM TO GROUP REPRESENTATIVE.