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

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, OLDMUTCOL or OMGSNAMCOL.

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 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) as a result of incorrect or incomplete information contained in this document, whether completed by self or any other person.