HOLLARD GUARANTEED ENDOWMENT PRODUCTS - POLICY MATURITY APPLICATION REQUEST
THIS APPLICATION REQUEST IS IN RELATION TO THE MATURITY PROCEEDS FROM THE GUARANTEED PLANS. NOTICE OF YOUR
INTENTIONS FOR SUCH PROCEEDS, AND ALL REQUIRED DOCUMENTS, MUST REACH HOLLARD BY THE 20TH OF THE MONTH
PRIOR TO MATURITY TO BE PROCESSED ACCORDINGLY.
1. Important Information
1.1.
1.2.
1.3.
1.4.
1.5.
1.6.
1.7.
1.8.
Hollard Investments is a division of Hollard Life Assurance Company Limited.
This application request relates to the maturity of your Hollard Guaranteed Plan.
Hollard Investments must receive your election and all required documentation by the 20th of the month prior to maturity, for your election to be
processed accordingly. The request will be processed on the 1st of the month.
If we do not receive notification of your intentions for the maturity proceeds from your policy by the 20th of the month prior to its maturity, the
maturity proceeds will be invested into the default Investment Portfolio option as selected by Hollard Life it is sole discretion. Please refer to the
maturity letter for further details.
Should you elect to withdraw the maturity proceeds please take note of the following:
a. Hollard Investments will make payment of proceeds by Electronic Funds Transfers only. No cheques will be drawn in payment of maturity
proceeds.
b. Hollard Investments will not be held responsible for any delays in payment of maturity proceeds due to the proof of banking details provided being
unclear, or in the event that no such proof is provided. Unclear or insufficient FICA documents may also cause delays in payment of maturity
proceeds.
c. If Hollard Investments has not received your completed form and required documents by the 20th of the month prior to maturity, your withdrawal
proceeds will be paid five (5) to seven (7) working days from the 2nd of the following month provided the required documents have been received.
d. No Third Party Payments will be permitted.
Should you elect to invest all or a portion of the maturity proceeds, a minimum investment amount of R50, 000 applies.
All documents can be sent via email to [email protected] or faxed to +27(0)11 351 3816.
Each page of this instruction must be initialled by you or the person acting on your behalf.
2. Document Checklist and Contact Person
Please take note of the requirements for the option you have selected and use the tick boxes provided to indicate you have included all documents. Complete
the details of the person to contact in the event that some or all of the requirements are not met.
2.1.
Option 1: Withdrawal of Maturity Proceeds in Part or in Full
Completed HOLLARD GUARANTEED ENDOWMENT PRODUCTS POLICY MATURITY APPLICATION REQUEST.
FICA documents as per the FICA requirements list available on the Hollard website www.hollard.co.za.
Proof of banking details (cancelled cheque or bank statement, excluding internet banking statements, not older than 3 months).
2.2.
Option 2: Investment of Maturity proceeds into Investment Portfolio(s).
Completed HOLLARD GUARANTEED ENDOWMENT PRODUCTS POLICY MATURITY APPLICATION REQUEST.
Certified copy of South African green bar-coded ID/new smart card ID or valid passport, with visible photograph and legible text.
FICA documents as per the FICA requirements list available on the Hollard website www.hollard.co.za.
2.3.
Details of person to contact in the event of outstanding requirements:
First Name:
Contact Details:
Surname:
Tel:
Capacity:
Email:
3. Policyholder Details
Policy Number:
Policyholder Name:
Contact Details:
Tel:
Fax:
Email:
Please indicate if these are new contact details
Yes
No
Hollard Life Assurance Company Limited (Reg. No.1993/001405/06), FSP No.17697is an authorised Financial Services Provider
22 Oxford Road, Parktown, Johannesburg, 2193, Tel: 0860 202 202, Fax: +27 (0)11 351 3816, Email: [email protected]
Guaranteed Investment - Policy Maturity Application Request - 210715
Page 1 of 5
4. Option 1: Withdrawal of Maturity Proceeds
PARTIAL WITHDRAWAL *
4.1.
Encashment Amount Required:
FULL WITHDRAWAL
R
OR
100%
* Please complete Section 5 with regards to the investment of the balance of the maturity proceeds.
4.2.
Banking Details for payment of proceeds. No third party payments will be made.
Bank Name:
Branch Name:
Acc. Name:
Acc. Number:
Acc. Type:
4.3.
Transmission
Cheque/Current
Code:
Savings
Other:
Please complete the following questions. Tick as appropriate.
a. Has your estate ever been sequestrated?
Yes
No
Yes
No
Yes
No
If “Yes”, please supply details below.
b. Are you currently insolvent?
If “Yes”, please supply details below.
c. Has the policy number provided in this document either been ceded or surrendered?
If “Yes”, please supply details below.
5. Option 2: Investment of Maturity Proceeds
The minimum investment amount is R50, 000.
5.1.
Value of maturity proceeds to be invested:
5.2.
Investment Portfolio Choice
R
Please refer to the Hollard Guaranteed Plan Investment Portfolio list for the range of Investment portfolios into which you may invest your maturity
proceeds.
Percentage of Invested
Investment Portfolio Name
Proceeds
%
%
%
%
%
%
100%
TOTAL
5.3.
Regular Withdrawal Option
You may schedule a regular withdrawal payment from your Matured Guaranteed Endowment. Please note the following:
a. Please supply proof of banking details for the bank account provided.
b. No third party bank payments are permitted.
c. The minimum regular withdrawal amount is R500.
d. The regular withdrawal payment will be processed via the sale of units from your Investment Portfolio(s).
e. Hollard Investments must receive this instruction or any changes or cancellation thereof 5 business days prior to the payment date.
f. If the payment date falls on a non-business day, the payment will be processed on the previous working day.
g. The regular withdrawal will be deducted proportionately across all Investment Portfolios.
h. Regular Withdrawal amount:
R
i.
Payment Frequency:
Monthly
j.
Regular Withdrawals to be paid on
1st
Quarterly
OR
24th
Bi-Annually
Annually
of the month in which it falls due.
Hollard Life Assurance Company Limited (Reg. No.1993/001405/06), FSP No.17697 is an authorised Financial Services Provider
22 Oxford Road, Parktown, Johannesburg, 2193, Tel: 0860 202 202, Fax: +27 (0)11 351 3816, Email: [email protected]
Guaranteed Investment - Policy Maturity Application Request - 210715
Page 2 of 5
k. Payment Details:
Bank Name:
Branch Name:
Acc. Name:
Acc. Number:
Acc. Type:
Transmission
Cheque/Current
Code:
Savings
Other:
Signature of Bank Account Holder:
6. Life Assured
IF THE POLICYHOLDER IS A TRUST, THIS SECTION IS MANDATORY AND THE LIFE ASSURED MUST BE A NATURAL PERSON
6.1.
6.2.
6.3.
Additional life assureds are permitted on the Guaranteed Income Plan after maturity.
In the case of the Policyholder being a natural person, it is assumed that the Policyholder is the first life assured and any details completed below will
be deemed to be a second life assured.
The death benefit will be paid to the nominated beneficiaries on the death of the last life assured.
Title:
Surname:
First Name(s):
ID/Passport No.:
Contact Details:
Date of Birth:
Home:
dd/mm/yy
Mobile:
Email:
Mandatory
7. Beneficiary for Ownership Details
7.1.
7.2.
7.3.
7.4.
A Beneficiary for Ownership is a natural person nominated by the Policyholder to become the owner of the policy in the event of Policyholder’s death,
should the Policyholder not be the last Life Assured.
If you are invested in the Hollard Guaranteed Income Plan, a Beneficiary for Ownership can only be nominated after the maturity date of the policy.
If no Beneficiary for Ownership is nominated, the deceased’s estate will become the Policyholder, should the Policyholder not be the last Life Assured.
Beneficiary for Ownership details:
Title:
Surname:
First Name(s):
ID/Passport No.:
Contact Details:
Relationship:
Home:
Mobile:
Email:
Mandatory
8. Beneficiaries Nomination for Proceeds
8.1. PLEASE TAKE NOTE THAT THE INDIVIDUALS NAMED BELOW WILL REPLACE ENTIRELY THOSE ALREADY NAMED ON THE POLICY AND ALL BENEFIT DUE
TO THOSE PREVIOUSLY NAMED WILL FALL AWAY.
8.2. A Beneficiary for Proceeds is a natural person nominated by the Policyholder to receive a benefit from the policy in the event of the death of the last life
assured.
8.3. If no beneficiary is nominated on this policy, it will be assumed, in the case of the policyholder being a natural person and on their death, that the
beneficiary will be the estate of the deceased. In the case of trust policyholder, beneficiary status will fall to the trust.
If you have nominated someone other than your estate or your spouse as beneficiary and you are married in community of property, in terms of the
Matrimonial Property Act, 1984, the consent of your spouse is required to authorise your beneficiary nominations. The policyholder indemnifies Hollard
against all and any claims by any spouse in the event this section is either not completed, or incorrectly completed.
8.4.
Are you married in community of property?
Yes
No
(If you are not married, please select NO)
If you answered YES to the above question please ensure the signature of a spouse below.
8.5.
I, the spouse of the applicant named herein, hereby agree to the nomination/s made by the applicant below.
Spouse Signature:
8.6.
Title
Date:
dd/mm/yy
Beneficiary Nominations:
First Name
Surname
Relationship
ID Number/Registration Number
Share of Benefits
(Total 100%)
%
%
%
%
%
Hollard Life Assurance Company Limited (Reg. No.1993/001405/06), FSP No.17697 is an authorised Financial Services Provider
22 Oxford Road, Parktown, Johannesburg, 2193, Tel: 0860 202 202, Fax: +27 (0)11 351 3816, Email: [email protected]
Guaranteed Investment - Policy Maturity Application Request - 210715
Page 3 of 5
9. Financial Services Provider Details and Declarations
Please tick and complete whichever is applicable.
9.1.
I have no financial advisor
9.2.
I wish to keep my existing financial advisor
(please complete details below in 9.4)
9.3.
I have a new financial advisor
(please complete details below in 9.4)
9.4.
Financial Advisor Details:
Practice Name (FSP):
FSP Number:
Financial Advisor Name:
Hollard Financial Advisor Code:
9.5.
Employer Financial Advisor Code:
(if applicable)
FAIS Declaration:
a. I/We declare that I/we am/are a licensed Financial Service Provider(s) and have made the disclosures required in terms of the Financial Advisory and
Intermediary Services Act, No. 37 of 2002 and subordinate legislation thereto, to the Policyholder.
b. I/We, the appointed FSP named herein, hereby declare that I/we have fully explained to the Policyholder named herein, the details and constraints
of the investment in question and have received confirmation from them of their understanding thereof, that Hollard Investments has the right to
review this investment application if at any time they feel the Policyholder does not understand the implications of their decision and the associated
consequences.
c. Further, I/we warrant that I/we have explained all fees that relate to this investment to the Policyholder and I/we understand and accept that the
Policyholder may withdraw his/her authority for payment to me/us in writing to Hollard Investments.
9.6.
FICA Declaration:
The financial services provider/representative declares and confirms in terms of the Financial Intelligence Centre Act, No 38 of 2001 (the Act) that:
a. I have identified and verified the details of the parties to this contract and transaction in terms of the requirements of Section 21 of the Act.
b. I have obtained copies of the clients’ identification and verification documents and will retain records thereof in terms of the requirements of
Section 22 of the Act.
c. I will perform these functions in accordance with the Regulation 4(b) exemption in place between my FSP, who acts as the primary accountable
institution herein, and the Product Provider.
Yes
9.7.
No
Policyholder Fee and Discretionary Mandate Declaration
This is only applicable if the FSP named herein holds a ‘Category II’ license with the FSB and is therefore an approved discretionary FSP.
a.
I/We confirm that I have entered into a mandate with the FSP named herein, who is an approved discretionary FSP.
b.
I/We confirm my understanding that if I/we have selected ‘No’, only transaction instructions received from, and signed by me/us, will be acted
upon.
I/We further confirm my understanding of the fact that if I have selected ‘Yes”, Hollard Investments will act on all transaction instructions received
from the nominated FSP irrespective of whether or not authorization for the transaction in question is received from me/us.
I/We indemnify Hollard Investments against any losses whatsoever that may occur as a result of transaction instructions carried out, where such
instructions are signed and submitted to Hollard Investments by the FSP without my/our knowledge.
I/We, the undersigned, confirm that I have read and completed, whether in my/our handwriting or not, this declaration and understand its
implications.
I/We confirm that the Policyholder named herein and I/We have agreed to the payment of the specified Annual Financial Advisor Fee, as specified
below.
c.
d.
e.
f.
Annual fee of:
g.
%
Yes
No
Excl. VAT (Annual Financial Advisor fee may not exceed 1% excl. VAT p.a.)
I/We furthermore confirm that I have signed this declaration of my own free will and I regard it as binding.
Financial Advisor Signature:
Date:
dd/mm/yy
Policyholder Signature*:
Date:
dd/mm/yy
Policyholder Signature*:
Date:
dd/mm/yy
Policyholder Signature*:
Date:
dd/mm/yy
* If the applicant is under the age of 18, this signature must be that of the Person Acting on Behalf of the Policyholder.
10. Policyholder Declaration and Signature
10.1. General:
a. I/We, the undersigned, am the legal owner of the policy numbered herein as detailed in this form, and hereby apply for the maturity proceeds of the
policy in question.
b. I/We confirm that all the statements contained herein are true and accurate at the time of signing this document.
c. I/We acknowledge and agree that all facsimile/electronic representation of all documents, including this application form, and any other instructions
hereafter, including mandates, consents, commitments and the like, which purport to emanate from me/us, shall be deemed to have been given by
me/us in the form actually received by Hollard Investments. I/We hereby waive all rights I/We may have or may obtain against Hollard Investments
arising directly or indirectly from any losses or damages that I/we may suffer because Hollard Investments acted on any purported
facsimile/electronic representation, and I/We indemnify Hollard Investments against any claims, demands or actions suffered by them because they
acted on a facsimile/electronic representation.
Hollard Life Assurance Company Limited (Reg. No.1993/001405/06), FSP No.17697 is an authorised Financial Services Provider
22 Oxford Road, Parktown, Johannesburg, 2193, Tel: 0860 202 202, Fax: +27 (0)11 351 3816, Email: [email protected]
Guaranteed Investment - Policy Maturity Application Request - 210715
Page 4 of 5
d. I/We hereby consent to the disclosure to and use by third parties (wherever situated) of my/our personal data for administrative and/or servicing
purposes in connection with the re-insurance, administration and/or servicing of this contract and related purposes, and for the purpose of receiving
communication regarding other products available from Hollard.
e. I/We confirm that I/We have read and completed, whether in my/our own handwriting or not, this declaration and understand its implications.
f. I/We furthermore confirm that I/We have signed this declaration of my own free will and I regard it as binding.
g. I/We confirm, by making my mark on this form either by way of my/our signature, an ‘X’ or my thumb print, that I/We have made this choice under
advisement from my FSP and that I/We fully understand the implications of my/our decisions and choices as outlined herein.
10.2. Investment of Maturity Proceeds:
a. I/We understand that the nature of the policy will change from a guaranteed policy to a market linked policy invested in the Investment Portfolios of
my choosing.
b. I hereby agree that the Policy Conditions and Investor Schedule, as provided on acceptance by Hollard Life of this Policy maturity application request,
form the basis of my contract with Hollard Life, together with any annexures, written amendments and endorsements. Hollard Life may amend the
terms and conditions of the policy after giving written notice of the proposed changes, provided that any such changes may not adversely affect any
accrued right or benefit that I may have under the policy, unless such a change is required by legislation or a regulatory authority.
c. I/We confirm that this Financial Advisor, as authorised representative of the FSP named herein, is my/our appointed Financial Advisor.
d. Ownership of the underlying assets will vest with the insurer and not the Policyholder.
e. I/We understand that Hollard Life will not be held responsible for any delays in processing as a result of the delays caused by, or initiated by the
Managers of the underlying Investment Portfolios.
f. I/We understand that I/We are solely responsible (in consultation with my Financial Advisor) for the selection of the investment portfolios to be held
within the policy and that Hollard Investments has not given me/us any advice in relation thereto.
g. I/We understand and accept all risks associated with this investment. In addition, I/We confirm that I/We have read all relevant documentation
associated with this policy.
h. I/We understand that Hollard Life does not guarantee the returns on the available investment portfolios, nor is responsible for the Investment
Manager charges or the performance fees levied by the Manager.
i. Hollard Life will levy an annual administration fee of 0.5% per annum excl. VAT on the Investment Account after the Maturity Date of the
Guaranteed Investment Option. We reserve the right to amend these fees at Hollard Life‘s sole discretion. You will receive prior written notice in the
event of a change.
j. Hollard Life will after the Maturity Date of the Guaranteed Investment Option levy an income tax charge of 15%, CGT tax charge of 5% and a
Dividend Withholding tax (DWT) charge of 15% on all Investment Portfolios excluding the Hollard Prime Unit Trust Funds for which no income tax or
CGT charges are levied. We reserve the right to amend these fees at Hollard Life’s sole discretion. You will receive prior written notice in the event of
a change.
k. The Managers of the underlying Investment Portfolios will levy an Annual Portfolio Management Fee and Initial Management Fee (if applicable). The
full list of Investment Portfolio Management fees are available on the Portfolio List which can be found on the Hollard website www.hollard.co.za.
Signed at
on this
(Place)
day of
(Day)
(Month)
(Year)
Policyholder Signature*:
Date:
Policyholder Signature*:
Date:
Policyholder Signature*:
Date:
* If the applicant is under the age of 18, this signature must be that of the Person Acting on Behalf of the Policyholder.
Hollard Life Assurance Company Limited (Reg. No.1993/001405/06), FSP No.17697 is an authorised Financial Services Provider
22 Oxford Road, Parktown, Johannesburg, 2193, Tel: 0860 202 202, Fax: +27 (0)11 351 3816, Email: [email protected]
Guaranteed Investment - Policy Maturity Application Request - 210715
Page 5 of 5