DEATH BENEFIT DISTRIBUTION REQUEST For use with the Collective Retirement Account (CRA)

Transcription

1 Application reference number For office use only *SFDBD0300F* DEATH BENEFIT DISTRIBUTION REQUEST For use with the Collective Retirement Account (CRA) Form purpose This form can be used by the Legal Personal Representatives of the deceased member s estate to indicate who they consider should receive the death benefits from the scheme. Important notes for completion Please use BLOCK CAPITALS only and blue or black ink. Please ensure all applicable sections of the form are completed clearly as missing or unclear information will result in a delay in processing, or even the return of this form. This form must be signed as appropriate and sent to the address below: Old Mutual Wealth, Old Mutual House, Portland Terrace, Southampton SO14 7AY 1 ACCOUNT DETAILS Please quote the member s client reference number, if known Member s Account number Member s full name Title Mr Mrs Miss Surname Other u please specify Full forename(s) 2 BENEFICIARY DETAILS Although I/we as Legal Personal Representative(s) of the deceased member s estate understand that Old Mutual Wealth Life & Pensions Limited as Administrator of the above scheme has absolute discretion, I/we request the cash sum payable from the scheme as a result of the Member s death should be paid as follows: Beneficiary 1 1 of 5

2 2 BENEFICIARY DETAILS () Beneficiary 2 Beneficiary 3 Beneficiary 4 3 MEMBER S MARITAL STATUS What was the marital status of the deceased? u please tick (3) Single Married Widowed Divorced Separated Civil partnership* of spouse/civil partner* Title Mr Mrs Miss Surname Other u please specify Full forename(s) of spouse/civil partner Date of birth of spouse/civil partner u dd mm yyyy * As defined by the Civil Partnership Act of 5

3 4 MEMBER S CHILDREN Did the deceased have any children? u please tick (3) If Yes, please complete this section. If No, please go to section 5. Child 1 Yes No Child 2 Child 3 Child 4 Please continue on a separate sheet if necessary and attach to this form. 5 DEPENDANT S DETAILS Did the deceased have any dependants other than their spouse/civil partner* or children u please tick (3) If Yes, please complete this section. If No, please go to section 6. Dependant 1 Yes No Reason for dependence *As defined by the Civil Partnership Act of 5

4 5 DEPENDANT S DETAILS () Dependant 2 Reason for dependence Please continue on a separate sheet if necessary and attach to this form. 6 DECLARATION AND AUTHORITY I/We are signing in our capacity as Legal Personal Representatives of the deceased member named above and declare that the information given on this form is true and correct to the best of our knowledge. *SFDBD0300X* Please ensure that all appointed legal personal representatives of the deceased sign this form. In some circumstances we may ask to see a copy of the grant of representation or a copy of the deceased s will before releasing any payment. 4 of 5

5 7 PAYMENT INSTRUCTIONS Please indicate payee details and where the payment should be sent. If the address is a bank or building society, we will need the full bank/building society details. Payee If you would like us to make the payment to a bank or building society, please complete the following: Name of bank/ building society Branch address Sort code Account number Account name Building society reference number (if applicable) Calls may be monitored and recorded for training purposes and to avoid misunderstandings. Old Mutual Wealth provides you with access to its investment platform. Within this platform you can open an ISA and Collective Investment Account provided by Old Mutual Wealth Limited and a Collective Retirement Account and Collective Investment Bond provided by Old Mutual Wealth Life & Pensions Limited. Old Mutual Wealth Limited and Old Mutual Wealth Life & Pensions Limited are registered in England and Wales under numbers and respectively. Registered Office at Old Mutual House, Portland Terrace, Southampton SO14 7EJ, United Kingdom. Old Mutual Wealth Limited is authorised and regulated by the Financial Conduct Authority. Old Mutual Wealth Life & Pensions Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Their Financial Services register numbers are and respectively. VAT number When printed by Old Mutual this item is produced on a mixed grade material, which uses a combination of recycled wood or paper fibre from controlled sources and virgin fibre sourced from well-managed, sustainable forests. PDF5621/ R/April of 5