Form of Discharge for Full or Partial Encashment Investment Portfolio Investment Portfolio+

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1 NOTE Please check with your financial adviser that this is the latest available document. Form of Discharge for Full or Partial Encashment Investment Portfolio Investment Portfolio+ This form should only be used to request a partial or full encashment from an Old Mutual Isle of Man Contract. November 2014 BEFORE COMPLETING AND SUBMITTING THIS FORM YOU SHOULD: Speak to your financial adviser to ensure you are following the most suitable course of action for your circumstances. You should be aware that in the first five years encashments are subject to restrictions. It may be that you are unable to access all or part of your capital during the initial five-year period. Any encashment may be subject to an early encashment charge. Full details can be found in the Investment Portfolio and Investment Portfolio+ General Conditions. The Old Mutual Isle of Man contracts are long-term insurance contracts. In terms of the General Code of Conduct for Financial Services Providers, if your financial adviser has advised you to replace this investment policy with any other financial product, he/she is obliged to disclose to you in writing the actual and potential financial implications, costs and consequences of the replacement, including: Fees and charges on the replacement policy in comparison to this contract, which have been or will be paid on this investment, including initial commission and ongoing advice fees, Note: You may pay some charges and fees twice. The amount of money that you can withdraw under the new policy may be less. The new policy will have a five year restriction period. Any differences in tax implications between the replacement product and your Old Mutual Isle of Man contract, including taxation of proceeds, Any material differences in investment risk between the replacement investment and this contract, Any encashment penalties which may be payable on encashment from the contract, Any differences in liquidity between the replacement investment and this contract, and All incentives, remuneration, commission or fees to be received on the replacement investment as well as any that may have been received on this contract. In addition, your financial adviser is required to provide you with a comparison with other financial products considered, the reason why the replacement investment is more suited to your needs than your Old Mutual Isle of Man contract and a summary of the information and material on which his/her advice is based. Your financial adviser is obliged to notify Old Mutual Isle of Man of this advice, in writing, no later than the date of submission of this Form of Discharge to its offices. Page 1 of 7

2 To complete this form: Use CAPITALS only Use blue or black ink Complete all relevant sections Do not use correction fluid; any amendments should be crossed out and signed by all Contract Holder s/signatories Missing or incorrect information will delay the processing of this form Once you have completed this form, please return to Cape Town Service Centre, Old Mutual International, 5th Floor H Block, Mutual Park, Jan Smuts Drive, Pinelands, 7405 (Tel) +27 (0) (Fax) ( ) service@omi-int.com Important Requirements and Guidance Notes Plan number In order to initiate an encashment please provide the documents indicated below ( ) Fully completed form. Page 6 must be signed by all Contract Holders/Signatories Old Mutual Isle of Man s policy is not to pay encashment proceeds to third parties. However, payment may be considered in the following circumstances: - To an account in the Contract Holder s name at a reputable well known and well regulated financial institution, agreed with Old Mutual Isle of Man, clearly referenced with the name of the Old Mutual Isle of Man Contract Holder, and upon receipt of a signed copy of the new investment application. - To an attorney/solicitor s account if licenced in a Code Schedule jurisdiction referenced with the name of the Contract Holder. - All requests for payment to third parties other than those stated above will be rejected. - Payment to a husband for a Contract in his wife s name and not his own, or vice versa. A copy of the marriage certificate and the payor s passport or national ID card will be required In order to action the payment of the encashment proceeds see certification requirements for the Contract Holders below: Individual Contract Holders/individual trustees An originally certified copy of a valid passport or national ID card (If this has not already been provided). An original or originally certified copy of proof of residential address, for example utility bill, bank statement, not older than three months from date of issue, (Postal correspondence or P.O. Box addresses will not be accepted unless a supply address is shown). Should the contract be jointly owned by a married couple and one of the owners is unable to produce proof of residential address due to all correspondence being addressed to their spouse, please contact your financial adviser. Trust/Corporate Contract Holders: Originally certified copy of a valid passport or national ID card for at least two directors, one of whom must be an executive director.(if this has not already been provided). Original or originally certified copy of proof of residential address, for example: utility bill, bank statement, not older than three months from date of issue, for at least two directors, one of whom must be an executive director if their address has changed. Certification Requirements: In the certification, preferably but not necessarily in the form of a stamp, the certifier must: State that he/she is a Commissioner of Oaths, Advocate, Lawyer, Solicitor, or Notary Public, Certify that he/she has seen the original document, that the copy is a true copy of the original and that it is a true likeness. Sign and date the certification, and Provide his/her full name and contact details in the form of a physical address and include telephone number. To start the encashment process, documentation can be faxed or ed through initially but the funds will only be released once all original documentation has been received and verified by Old Mutual Isle of Man. Page 2 of 7

3 A Details of Contracts to be encashed Trust/Corporate name Trust/Corporate name Details of Contract Holder(s) Contract Holder 1 Contract Holder 2 Contract Holder 3 Contract Holder 4 Contract Holder 5 Contract Holder 6 Contact details for any queries relating to this encashment: The contact must be a Contract Holder, Signatory or financial adviser. We cannot release information to a third party without the appropriate authorisation. Postal address: (correspondence will be sent to this address) address Page 3 of 7

4 B Instruction Please tick here if you have taken professional advice on the best way of cashing in your policy, taking your present tax status into account. ( ) Full encashment of the Plan Is this a full encashment of the Plan? ( ) Yes By ticking above, I/we acknowledge that the amount paid constitutes full and final settlement and, where applicable, will incur early encashment charges. Please refer to the General Conditions. Proceed to Section C Alternative encashment instructions I/We require the maximum partial encashment (in base currency) ( ) Specific Cash Amount Value (Specify currency. If currency not confirmed base currency will be used) Specific Partial Cash Amount Please enter a range, for example 1 to 5, or choose a value for which Old Mutual Isle of Man will calculate the appropriate number of policies for encashment. We will encash whole policies as close to the value needed, and then we will partially encash the next policy in the sequence to achieve your requested amount. Policy to OR Value (Specify currency) If you do not have the cash available in your policy, you must sell from your investment to fund the requested encashment. Please provide the required information in the following section, for example, number of units or value. Currency Currency ( ) US$ HK$ SEK ZAR Other (Please state, refer to guidence notes for other currencies) Sale of specific investments to fund requested encashment Please state in the space below which specific investment(s) held in your policy should fund your requested encashment. Please clearly indicate below the percentage or value of each investment to be sold. Please note that if a percentage is selected, this will be accepted as a percentage of the total withdrawal amount inclusive of any current overdraft. If you wish to add more investments to be sold, please attach a photocopy of this page, attach the details with this form and tick here. ( ) Investment name (Please include sedol/isin/rsid) Percentage or Value (please indicate) Please tick if you wish to re-register/transfer assets. ( ) Page 4 of 7

5 C Payment details Bank account details Please send the encashment proceeds via electronic transfer to the following account. Note: Where a separate addendum has been provided with banking details, this must be signed by all Contract Holders/Signatories. Please select the applicable currency listed below ( ): US$ AUD CHF ZAR BENEFICIARY BANK (Always complete this section) Bank name Bank address Account holder s name Postcode Country Account number Sort code (GBP only) - - International Bank Account Number (IBAN) SWIFT/bank/ABA code Branch code - - Reference to be quoted CORRESPONDENCE/ROUTING BANK (To be completed for all currencies except GBP and ZAR) Correspondent bank name Account number Sort code - - International Bank Account Number (IBAN) SWIFT/bank/ABA code Branch code - - Reference to be quoted Page 5 of 7

6 D Declaration I/We instruct Old Mutual Isle of Man to make payments as detailed on page 5 and understand: The Contract General Conditions surrounding encashments as well as the early encashment charges relevant to the contract and any tax implications. The current minimum request that will be accepted is as detailed in the Contract General Conditions. That payments will incur bank transmission charges. The charges that may be levied against this encashment are detailed in the Contract General Conditions. That encashments will be made in accordance with any applicable legislation. Certain funds may have limited redemption periods applied from time to time and this may delay any encashments, exchanges of units, or switches out from such a fund. Failure to complete all relevant bank details or provide all required documentation will delay payment for which Old Mutual Isle of Man will accept no liability. Old Mutual Isle of Man s obligation is to pay proceeds in the currency in which the Contract is denominated. If payment is made in a currency other than the Contract denomination, this may result in delays arising from availability of forex or other reasons beyond the control of Old Mutual Isle of Man. Where a full encashment has been paid, this will be in full and final settlement and Old Mutual Isle of Man will be discharged from all liabilities and claims arising by virtue of this request. Once payment has been released into the banking system, Old Mutual Isle of Man can accept no liability for delays or costs. Signature(s) of Contract Holder(s)/Authorised Signatories. All signatures must be dated. Note: If it is a trust company/company, an up-to-date signatory list with signing powers is required if the signatories have changed or the signatory list has not been provided during the previous two years. Signature Print name Date 1 D D M M Y Y Y Y 2 D D M M Y Y Y Y 3 D D M M Y Y Y Y 4 D D M M Y Y Y Y 5 D D M M Y Y Y Y 6 D D M M Y Y Y Y If the Contract is jointly owned, this form must be signed by all Contract Holders. If this form is not dated, Old Mutual Isle of Man will not be able to process the instruction. If the Contract is under Security Cession, the Security Cessionary must sign and date this request in the boxes included below. Signature of Cessionary or authorised signatory. Signature Print name Date 1 D D M M Y Y Y Y 2 D D M M Y Y Y Y 3 D D M M Y Y Y Y Page 6 of 7

7 Old Mutual Isle of Man, Branch of Old Mutual Life Assurance Company (South Africa) Limited, is registered in the Isle of Man under number F and whose principal place of business is King Edward Bay House, King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0) Fax: +44 (0) Authorised and regulated by the Isle of Man Insurance & Pensions Authority. Old Mutual Life Assurance Company (South Africa) Limited is incorporated in South Africa (reg. number: 1999/04643/06). Registered office: Mutualpark, Jan Smuts Drive, Pinelands, Cape Town, South Africa. Old Mutual Life Assurance Company (South Africa) Limited is a registered long-term insurer and a licensed financial services provider. A Member of the Group OMISA/IP+/001/1.0/1114 (rename) Page 7 of 7