Replacement Policy Owner change request t&c's

IMPORTANT NOTES

• I, the undersigned, declare that the information provided in this document is complete and accurate.

• Applicable to Replacement Policy Owner Changes only

• The replacement policy owner will have no rights to the contract or the benefits until written notice of the death of the contracting party has been received by Old Mutual.

• The instruction will be invalid until this signed declaration together with all requirements needed is received by Old Mutual.

• This replacement policy owner nomination will supersede any existing nominations for the specific contract(s) specified.

• I cannot hold Old Mutual responsible for any loss if I give the incorrect information.