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Beneficiary nomination form - beneficiary nomination – trusts

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  • pg 1
									beneficiary nomination – trusts, charities
or companies
• This document may be used in relation to both Life Account and Life Account 2 Contracts.
• Before completing the Beneficiary Nomination you should seek professional financial advice.
• Only use this form where you are nominating a trust, charity or company. If you wish to appoint an individual person, please complete a
  Beneficiary Nomination – Individuals form available from our website www.oldmutualinternational.com or refer to your local Old Mutual
  Guernsey office.
• You can nominate up to a maximum of two trusts, charities or companies to receive the benefits payable under the Contract, subject to any
  succession restrictions. Any benefits payable will be in equal shares.
• This Beneficiary Nomination will take effect on the death of all the Relevant Lives Assured and Contract Holders only.
• As Life Account is issued as multiple Contracts, this Beneficiary Nomination will apply to all Contracts within the Plan.
• This form must be signed by all Contract Holders.
• Any future change of Nominated Beneficiaries must be confirmed in writing to us and an endorsement will be issued to confirm our acceptance of
  the change.
• International anti-money laundering regulations require Old Mutual Guernsey to identify parties to each transaction. In the case of some registered
  charities, recognised trusts (such as the National Trust) and certain Government recognised retirement funds, these requirements may be relaxed.
  Private trust and/or non-registered charities may require significant verification of trustees and/or beneficiaries. In any case, please contact
  Old Mutual Guernsey office to ascertain the extent of these requirements.
• Please note if you nominate a beneficiary who is resident in South Africa, they will have an obligation to declare this to the Reserve Bank.
• Old Mutual Guernsey will not be responsible for any legal or taxation consequences arising from the use of this form.




Beneficiary Nomination in respect of
Contract number      from                                                               to

Contract Holder(s)   1.                                                                4.
name(s)
                     2.                                                                5.


                     3.                                                                6.


SECTION C MUST BE COMPLETED. IF IT IS NOT, OLD MUTUAL GUERNSEY WILL NOT BE ABLE TO PROCESS THIS REQUEST.



 Contract Holder(s) signature(s)




                                                                                                                                          page 1 of 5
    A. Trusts nomination
    Nomination 1           Beneficiary interest*                       %   *Total must add up to 100% across all nominations.


    Trust name

    Created on                                                         Please state jurisdiction of trust
    (please enter date)     D     D    M    M      Y    Y    Y     Y
   Name(s) of
   Trustee(s)




    Contact details for nomination 1 (Trustee(s))
   Title                   Mr              Mrs              Miss           Ms                 Other

   Surname

   Full Forenames

   Any former, maiden or
   other names known by
   Address




                                                                                                   Country

   Telephone number         preferred contact details                                              Fax number          preferred contact details

   E-mail address           preferred contact details

   Nomination 2            Beneficiary interest*                       %   *Total must add up to 100% across all nominations.


   Trust name

   Created on                                                          Please state jurisdiction of trust
   (please enter date)      D     D    M    M      Y    Y    Y     Y
   Name(s) of
   Trustee(s)




   Contact details for nomination 2 (Trustee(s))
   Title                   Mr              Mrs              Miss           Ms                 Other

   Surname

   Full Forenames

   Any former, maiden or
   other names known by
   Address



                                                                                                  Country

   Telephone number         preferred contact details                                             Fax number           preferred contact details

   E-mail address           preferred contact details

   SECTION C MUST BE COMPLETED IN ALL CASES. IF IT IS NOT, OLD MUTUAL GUERNSEY WILL NOT BE ABLE TO PROCESS THIS REQUEST.


     Contract Holder(s) signature(s)

page 2 of 5
B. Charity or company nomination
Nomination 1            Beneficiary interest*                  %      *Total must add up to 100% across all nominations.


Charity/Company
name
Registered office



Charity/Business

Charity fund-
raising number

Ownership details
I confirm that company shares are not held in bearer form.         Note: applications from companies issuing bearer shares will not be accepted.



Please complete either i) or ii)

i) The company is quoted on a recognised stock exchange, either directly or as a subsidiary.

a) Stock exchange                                                                  b) Listed name

c) If a subsidiary, please confirm relevant details


ii) The company is NOT quoted on a recognised stock exchange, either directly or as a subsidiary.
Please confirm ownership details, including, but not limited to, number of shares and names of holders with more than 5%.




Contact details for the charity or company
Title                   Mr              Mrs           Miss          Ms                  Other

Surname

Full Forenames

Any former, maiden or
other names known by
Address




                                                                                             Country

Telephone number         preferred contact details                                           Fax number           preferred contact details

E-mail address           preferred contact details

SECTION C MUST BE COMPLETED IN ALL CASES. IF IT IS NOT, OLD MUTUAL GUERNSEY WILL NOT BE ABLE TO PROCESS THIS REQUEST.




  Contract Holder(s) signature(s)




                                                                                                                                                   page 3 of 5
   B. Charity or company nomination (continued)
   Nomination 2            Beneficiary interest*                  %        *Total must add up to 100% across all nominations.


   Charity/Company
   name
   Registered office



   Charity/Business

   Charity fund-
   raising number

   Ownership details
   I confirm that company shares are not held in bearer form.         Note: applications from companies issuing bearer shares will not be accepted.



   Please complete either i) or ii)

   i) The company is quoted on a recognised stock exchange, either directly or as a subsidiary.

   a) Stock exchange                                                                  b) Listed name

   c) If a subsidiary, please confirm relevant details


   ii) The company is NOT quoted on a recognised stock exchange, either directly or as a subsidiary.
   Please confirm ownership details, including, but not limited to, number of shares and names of holders with more than 5%.




   Contact details for the charity or company
   Title                   Mr              Mrs           Miss          Ms                  Other

   Surname

   Full Forenames

   Any former, maiden or
   other names known by
   Address




                                                                                                Country

   Telephone number         preferred contact details                                           Fax number           preferred contact details

   E-mail address           preferred contact details

   SECTION C MUST BE COMPLETED IN ALL CASES. IF IT IS NOT, OLD MUTUAL GUERNSEY WILL NOT BE ABLE TO PROCESS THIS REQUEST.




     Contract Holder(s) signature(s)




page 4 of 5
C. Declaration
I/We acknowledge that:
• any Beneficiary Nomination will be effective only insofar as the claims of a valid security cessionary have already been met;
• any absolute assignment negates/cancels any Nominated Beneficiary selections immediately the assignment takes place, and;
• this Beneficiary Nomination will be effected in accordance with the Life Account General Conditions prevailing at the time.
Signature(s) of Contract Holder(s)                                                                                         This date cannot be more than three months prior to our receipt of the form

1.                                                                             Date of signature           4.                                                                             Date of signature



2.                                                                             Date of signature           5.                                                                             Date of signature



3.                                                                             Date of signature           6.                                                                             Date of signature



Please note that if the Contract(s) is/are jointly owned, this/they must be signed by all authorised signatories. If this form is not signed and dated, Old Mutual Guernsey will not be able to process
the request.




                                                                                                                                            Old Mutual Guernsey, whose principal place of business is
                                                                                                                 Albert House, South Esplanade, St Peter Port, Guernsey, GY1 1AW, Channel Islands,
                                                                                        is a branch of Old Mutual Life Assurance Company (South Africa) Limited which is incorporated in South Africa
                                                                                                                  Registered office: Mutualpark, Jan Smuts Drive, Pinelands, Cape Town, South Africa.
                                                                                                                                                                  Registered number: 1999/04643/06
IINT10-145/June 2010                                                                                                                                                                               FP0017
                                                                                                                                                                                           page 5 of 5

								
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