PERSAL DEDUCTION AUTHORIZATION Do you grant permission for Old Mutual to arrange with your employer for payment of my premiums, including increases that may be made during the life of the policy. Do you grant permission for Old Mutual to gather information from my employer or third parties to facilitate the payment process? Do you understand that the first deduction from your salary will start at the end of next month or as soon as possible thereafter but within 3 months of signing this form? Are you aware that your request can be declined should your employer not give consent to do this deduction from your salary? Do you confirm that the information you have provided is complete and correct? Do you authorise the Accountant of the Department/Administration of Kunene Makopo Risk Solutions to deduct from your salary each month applicable for the cover selected with effective from the end of this month? Do you understand that it is from Old Mutual that you are obtaining your policy from? Do you understand that it is until such time as you cancel this authorization in writing, or until you substitute it with a new authorization? On which day of the month would you like pay this amount to Old Mutual? MANDATE Do you acknowledge that all payment instructions issued by you shall be treated by your above-mentioned Bank as if the instructions have been issued by you personally? * CANCELLATION Do you agree that although this Authority and Mandate may be cancelled by you, such cancellation will not cancel the Agreement and that you shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you? * ASSIGNMENT Do you acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party? * From where are you signing this contract from? * What is the signature date? *
If you are about to complete and sign today, then enter today's date.
How did you hear about us? * CLAIMS PROCEDURE Do you understand that the specified benefits will be paid to the beneficiary, the estate of the member, or on request of the beneficiaries to the administrator at the death of the assured, who in shall pay the benefits to the person/s legally entitled thereto? Do you understand that claims must be reported to The Administrator within 6 (six) months of the death of the assured? Do you understand that the insurer and Kunene Makopo reserves the right to cancel the policy and to declare all premiums paid by the policyholder in terms of the policy forfeited. If there is any evidence of or attempted submission of a fictional claim, or fraud or mirepresentation? Do you understand that claims must be accompanied by 7 (seven) documents, which are: (1) an official or certified copy of the original death certificate, (2) a certified copy of the deceased's and beneficiary's ID documents, (3) a police statement in case of death due to unnatural causes, (4) certified copy of the BI 1663 The Administrator may reauest additional documentation from time to time, (5) an affidavit by the claimant confirming dependency of deceased, (6) policyholder membership certificate and bank details and (7) permission of the beneficiary for deposit of benefit?
Our complaints resolution policy can be obtained by contacting the complaints officer as detailed on the disclosure document.Complaints which are not resolved to your satisfaction may be referred to:
Particulars of Long-term Insurance Ombud at: Registrar of Long-term Insurance at: Private Bag X45, Claremont, 7735 __________ TEL(021) 657 5000 __________ FAX (021) 674 0951 __________ PO Box 35655, Menlopark __________ Tel (012) 428 8000 __________ Particulars of FAIS Ombud at: Mr Charles Pillai ___________ P O Box 74571, Lynnwood Ridge, 0040 __________ TEL: (012) 470 9080/99 _________ FAX: (012) 348 3447
RIGHT TO CANCEL Do you understand that after the Insurer has accepted your application for assurance, you may, if you decide, instruct the Administrator to cancel your policy and refund your premiums? Do you understand that the Administrator may deduct the cost of any risk cover you enjoyed under the policy before it was cancelled?
This instruction must be submitted in writing, via mail or email, to the administrator within 30 (thirty) days after receipt of the membership certificate. You amy only submit such a cancellation instruction if no benefits have been paid or claimed or an event insured against has not yet occured.
DISCLOSURE DOCUMENT Do you acknowledge that as a long-term insurance policyholder, you have the right to the following information?
(Please retain a copy of this Disclosure Document for your records) Product Supplier (Insurer) with whom your policy is placed. __________
Company Name: Old Mutual Insurance Company Limited __________ Physical address: Mutualpark, Jan Smuts Drive, Pinelands, 7405, South Africa __________ Fax: 021 509 3181 __________ Email: GSFMQueries@oldmutual.com __________ Postal address: P.O BOX 73, Cape Town, 8000 , South Africa __________ Telephone Number: (021) 509 9111 __________ Website:www.oldmutual.co.za
MANDATED INTERMEDIARY Do you acknowledge that Kunene Makopo Risk Solutions is licenced as a Financial Services Provider, entitled to provide advice and intermediary services on your behalf in respect of the policy underwritten by Old Mutual Life Assurance Company Limited as product supplier?
Compliance Officer: Ruby Mosime - Mosime Consult - Compliance Practice No, 7011, Mobile: 084 290 2833
CONFIRMATION (1) Do you understand and agree that the consequences and importance of accurate disclosures of all material facts. __________ (2) Do you understand and agree that all fields on this form were fully completed digitally by you (as per your full names on this "agreement") before you signed them? __________ (3) Do you understand and agree that you have been made aware of the contents of all documents used in the purchase of this policy? __________ (4) Do you understand and agree that this policy does/does not replace an existing life (funeral) policy? Do you understand and agree that if it does, I have completed the required additional paperwork and that the consequences of policy replacement have been explained and understood? __________ (5) Do you understand and agree that product is sold to you on a non-advisory basis and that for advise you can contact Kunene Makopo Risk Solutions on +27 (0) 10 900 1346? __________ (6) Do you understand and agree that you are fully aware of the waiting period provisions of this policy? _________ (7) Do you understand and agree that you are fully aware of the premium payment provisions and consequences of non-payment of this policy and that a debit order/salary deduction form has been completed and signed by member? __________ (8) Do you understand and agree that you hereby apply for the benefits contained in this document and you have declared that you have not withheld and material information? __________ (9) Do you understand and agree that this application and declaration shall be the bases of the contract between you, Kunene makopo Risk Solutions and Old Mutual Life Assurance Company? __________ (10) Do you understand and agree that you further appoint Kunene makopo Risk Solutions as your mandatory broker to amend, cancel and transfer my policy for your benefit? _________ (11) Do you understand and agree that any willful misrepresentation in application will invalidate any benefit under this Policy and all premiums paid will be forfeited in this event? __________ (12) Do you understand and agree that you undertake to abide by the terms and conditions of the Policy? __________ (13) Do you understand and agree that the insurer shall not be liable for any amount until it has accepted this application and first premium? __________ (14) Do you understand and agree that the premium withdrawals hereby authorised will be processed by persal or debit order and that you agree to pay any bank charges related to this debit order instruction? _________ (15) Do you understand and agree that this authority may be cancelled by you giving the Insurer 30 days’ notice in writing but you understand that you shall not be entitled to any refund of amounts which have been withdrawn while this authority was in force if such amounts were legally owing to the Insurer? _________ (16) Do you understand and agree that you hereby grant permission that the premium may be deducted against your monthly salary on a monthly basis or against your bank account on a monthly basis until you cancel this authorisation in writing or substitute it with a new authorisation? _________ (17) Do you understand and agree that you have been informed of your rights in terms of the Policyholder Protection Rules and that you declare that you have read and understood the terms and conditions attached to this policy? Do not want to receive any special promotions from Kunene Makopo Risk Solutions by sms, telephone, e-mail or post? * From where are you signing this contract from? What is the signature date?
If you are about to complete and sign today, then enter today's date.
Protection of Personal Information Act *