Stop order change request terms and conditions

IMPORTANT NOTES

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

• I give Old Mutual permission to arrange with my employer to deduct my premium from my Salary and any contractual premium increases will be included in these deductions. I understand that the first deduction should take place by the end of the next month, following the date on this application, or as soon as possible afterwards.

• 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.

• I, the undersigned, hereby indemnify Old Mutual against any claim which may be made against it for the proceeds of the abovementioned benefit(s)due to incorrect or incomplete information contained in this document, whether completed by self or any other person.