Application for cash withdrawal

Transcription

1 Application for cash withdrawal Policy/Benefit number Cash value isk fund value Optional cash value Debt settlement Optional maturity value Voluntary purchase annuity/lump-sum investment plan We recommend that you contact your personal financial adviser before making any changes to your financial portfolio. EQUIEMENTS So that Momentum can process your application, we require the following: 1. This form fully filled in, in black ink and in block letters Copy/ies of the certified identity document/s that prove/s your identity/ies 3. A valid and signed quotation should accompany applications for optional cash values, debt settlement and partial withdrawal from the risk fund value (where applicable) 4. Fill in a separate application for each policy number or benefit number 5. A copy of your original, complete bank statement or a cancelled cheque in confirmation of your bank details 6. Trusts: 6.1 The trust deed. 6.2 A current and valid letter of appointment issued by the Master of the High Court, setting out who has been appointed as trustees. 6.3 A resolution signed by the designated trustees, authorising certain trustee/s to act on behalf of the trust (only necessary where not all the trustees will be signing documents). This form is only valid for three months. Please make sure that all the requirements defined in this form, are met. DEFINITIONS 1. Policyholder/s The legal owner/s of the policy or benefit, who can be the purchaser/s and/or the annuitant and/or the cessionary. Cessionary/ies The legal entity/ies or institution/s to which ownership of the policy or benefit has been partially or fully transferred by way of a cession (eg bank). 3. Identity document Baptismal certificate, birth certificate, card driving licence (both sides) or official document with a photograph, the identity number, initials and surname of the person. 4. Marriage contract If the policyholder was married in community of property after 1 vember 1984, the policyholder s spouse must sign the form. 5. Trust: A trust registered with the Master of the High Court. 6. Trustee: A person duly appointed by the Master of the High Court in a letter of appointment. BANCH/BOKE: CONTACT DETAILS eturn to: Broker Client 1 of 5 MOMAD E Momentum Group Limited 268 West Avenue Centurion 0157 PO Box 7400 Centurion 0046 South Africa ShareCall Cell Telephone (012) Fax (012) Business hours 07:00-19:00 [email protected] eg. no. 1904/002186/06 egistered as a Financial Services Provider under the Financial Advisory and Intermediary Services Act, 2002

2 Application for cash withdrawal Section A: Personal and policy/benefit details The policyholder must fill in this section (see definition 1) 1. Policy number Policyholder (full names) Postal address Title (eg Dr/Prof/Mr/Ms) Gender M F SA ID Yes ID/egistration number of birth M M Y Y Y Y Language ENG AF Telephone - work (code - number) Telephone - home (code - number) Fax - work (code - number) Fax - home (code - number) Cell number How would you like us to reply to this request? Mail Tel Fax Additional policyholders 1. t applicable to Myriad policies 3. Insured life (if other than policyholder) Title (eg Dr/Prof/Mr/Ms) Gender M F SA ID Yes ID number of birth M M Y Y Y Y Language ENG AF Telephone - work (code - number) Telephone - home (code - number) Fax - work (code - number) Fax - home (code - number) Cell number 4. Cessionary Additional cessionaries 1. Section B: Options 1. Cash value (early cancellation value) 1.1 Cash value (cancel the policy) 1.2 Cash value (cancel the pure endowment rider savings benefit and continue the policy) te: We calculate the effective values on the day that we receive the last outstanding requirement. The payment or reduction of any values by Momentum Only one partial withdrawal and one policy loan may occur during a restriction period. The reason I/we no longer need this policy is: If a new application replaces the policy, please state the insurance company. 2 of 5

3 Section B: Options (continued) Optional cash value (cash withdrawal from the investment account) 1 Optional cash value 2 Debt settlement Debt amount to be settled I/We acknowledge that taking an optional cash value could substantially affect the future cash values, death claim value and ultimate maturity value of my/our policy. (A quotation is available that will clearly show you the effect of this cash withdrawal on your policy.) Do you require a quotation? Yes (If Yes, you must include a signed quotation to complete this transaction) Signature M M 2 0 Y Y te: We calculate the effective values on the day that we receive the last outstanding requirement. The payment or reduction of any values by Momentum Only one partial withdrawal and one policy loan may occur during a restriction period. 3. Optional maturity values (this cash withdrawal is available only on Lifegro Universal policies on the tenth anniversary of the policy and every five years thereafter). Policy number a. Take the full optional maturity value (continue the policy) b. Take part of the optional maturity value (continue the policy) te: We calculate the effective values on the day that we receive the last outstanding requirement. The payment or reduction of any values by Momentum 4. isk fund value (for Myriad policies) 4.1 isk fund value (cancel the policy) 4.2 Take part of the risk fund value (continue the policy) 4.3 isk fund value (cancel the benefit) 4.4 Take part of the risk fund value (continue the benefit) If you selected 4.3 or 4.4, please complete the benefit details Policy/Benefit number Benefit name Insured life Cessionary Additional cessionaries 1. I/We acknowledge that taking part of the risk fund value could substantially affect the future risk fund value of my/our policy or benefit. (A quotation is available that will clearly show you the effect of this withdrawal on your policy.) Do you require a quotation? Yes (If Yes, you must include a signed quotation to complete this transaction) te: We calculate the effective values on the day that we receive the last outstanding requirement. The payment or reduction of any values by Momentum Only one partial withdrawal may occur during a restriction period. 3 of 5

4 Section B: Options (continued) The reason I/we no longer need this policy or benefit is: If a new application replaces the policy or benefit, please state the insurance company. 5. Early cancellation of a voluntary purchase annuity/lump-sum investment plan Annuity number Voluntary purchase annuity Commuted value Lump-sum investment plan Commuted value This payment represents the future instalments for the annuity. I/We accept the full commuted value as the full and final settlement of Momentum s liability under the annuity. te: We calculate the effective values on the day that we receive the last outstanding requirement. The payment or reduction of any values by Momentum Section C: Personal bank details The government recently implemented the Financial Intelligence Centre Act (FICA). Section 21 of the Act stipulates that Momentum must fully identify a third party before entering into any transaction with such an entity. As a result, we decided that our company will not allow third-party payments. Pay the applicable value into my bank account Name of institution Branch Type of account Current Savings Transmission Account number Bank branch code Name of account holder Bank telephone number Please provide us with a copy of your complete bank statement or a cancelled cheque in confirmation of your bank details. Signature of policyholder M M 2 0 Y Y Section D: tification to cedent The financial institution must fill in this section for collateral security cessions. I/We,, confirm that the debt for which the policy has served as security is due and payable and that I/we have informed the cedent that I/we will cancel or take an optional cash value or risk fund value on policy number/benefit number 4 of 5

5 Section E: Declaration I/We warrant that: 1. I am/we are the legal owner/s of the policy or benefit, and competent to deal with the policy or benefit. My/Our estate/s is/are solvent and has/have never been surrendered or sequestrated. 3. I/We have not ceded or pledged the policy or benefit to anyone either by antenuptial contract or otherwise, except in favour of Momentum as security for a loan on the policy or benefit and/or 4. I/We specifically authorise Momentum to pay the proceeds due to me/us into the account indicated, and I/we indemnify Momentum against all actions, suits, claims, demands, costs and expenses resulting from Momentum giving effect to my/our instruction. I/We acknowledge that such payment will be made in full settlement of any liability Momentum may have in terms of my/our instruction to Momentum. 5. I/We warrant that I am/we are the legal owner/s of the policy or benefit and entitled to deal with it. I/We indemnify Momentum against all actions, suits, claims, demands, costs and expenses against Momentum by any third party with more claim to ownership than me/us in relation to the policy or benefit. 6. If I/we have selected options 1 or 3A in section B, I/we cede, subject to the existing terms of the policy, all my/our rights, title and interest under the policy to Momentum Connect (Pty) Limited, in consideration for which I/we accept payment of the cash value from Momentum on behalf of Momentum Connect (Pty) Limited. I/We acknowledge that Momentum Connect (Pty) Limited, or its legal successors, may have access to my personal information contained in this policy. 7. I/We accept that if any money, plus interest, is payable to me/us, Momentum will determine the interest rate in accordance with its policy at the time. Signed at M M 2 0 Y Y 1. Signature of policyholder/duly authorised person Signature of policyholder/duly authorised person 3. Signature of policyholder/duly authorised person 4. Signature of cessionary 5. Signature of spouse if married in community of property (see definition 4) In the event of a legal entity: 1. egistration number I am/we are duly authorised to represent the legal entity Signature 3. Name in block letters 4. Designation 5 of 5