2-in-One Voluntary Contribution Adjustment request t&c's

DEBIT ORDER

I give Old Mutual permission to arrange for the payment of the premiums with my bank. I understand that the premium will be deducted on the day that I have chosen or on my salary payment date where Old Mutual is able to get this information. I understand that I have agreed to pay the starting premium and any contractual increases to it over the term of the contract. I understand that up to two outstanding premiums will be included in these deductions. I understand that any premiums for an Old Mutual product will show on my bank statement as OMGPSCHEME or OLDMUTCOL.

I further understand that, if Old Mutual is unable to collect my premium on the date that I have chosen or on my salary payment date because there was not enough money in my account, Old Mutual, with the help of my bank, will track my account and deduct my premiums when there is enough money in my account. I understand that any premiums for an Old Mutual product will show on my bank statement as "OLD MUTUAL" with a reference number.

STOP ORDER

I give Old Mutual permission to arrange with my employer to deduct my contribution from my salary.

I understand that any contribution increases will be included in these deductions.

I understand that the first deduction should take place at the end of the next month

STATUTORY INFORMATION

Unit trusts are generally medium- to long-term investments. Past performance is no indication of future performance. Shorter term fluctuations can occur as your investment moves in line with the markets. Fluctuations or movements in exchange rates may cause the value of underlying international investments to go up or down. OMIA will invest your contributions into the Old Mutual Money Market Fund Class B5 (the Fund), held with Old Mutual Unit Trust Managers Limited (OMUT).The Fund is a conservative low risk fund and there are no guarantees on your capital. It is your duty to ensure that you understand the investment risks associated with investments in the Fund and you accept these risks by investing in the Fund. The total return is primarily made up of daily interest, but may also include any gain/loss on any particular instrument. In most cases this will merely have the effect of increasing/decreasing the daily yield, but in an extreme case it can have the effect of reducing the capital value of the Fund.

INVESTOR'S SIGNATURE AND DECLARATION

I confirm that all the information provided on this form is correct.

I warrant that I have full power and authority to enter into and to conclude these transactions.

I understand that the investment mandate that I agreed to when I applied for my 2-IN-ONE SAVINGS PLAN, is still applicable.

I acknowledge that Old Mutual may approve or decline this request subject to the terms in the policy contract(s).

I understand that my contribution(s) will be collected by Old Mutual and paid over to OMIA. OMIA will invest my contribution in the Old Mutual Money Market Fund B5.

If you request to adjust your Short Term Pocket contributions during the automatic premium increase period (approximately April to June), the new contribution will not reflect on the premium increase letter we send you in May/June but we will adjust it accordingly.

I understand that, if I indicate that I want to increase my contribution to the Short Term Pocket of my 2-IN-ONE SAVINGS PLAN and fail to pay the increased amount within 4 months of this instruction, Old Mutual will deduct the contribution that applied before I gave this instruction.

I have read, understood and agree to this declaration.