Address: Old Mutual Building, 30 Glyn Jones Road, Blantyre | P.O.

Box 393, Blantyre, Malawi

Telephone: 265 (1) 820 67
Website: www.oldmutual.co.mw

Please print in block letters using black or blue ink. Application number
Tick blocks where applicable.
An insurance agent who assists an applicant to complete this form shall be deemed to have done so as the agent of the applicant.
A. PERSONAL DETAILS

Title

First name(s)

Surname

Previous surname

Date of birth Identification number

Type of Identification National ID Passport Driver’s licence Driver’s ID Voter’s card

Marital status Married Single Divorced Widowed Gender Male Female

Country of birth Nationality (Citizenship)

Do you pay tax in another country? Yes No Tax reference number

Name of country in which you pay tax

Source of income Salaried Self-employed Commission

Your net monthly income MK29,500 - MK49,999 MK50,000 - MK69,999 MK70,000 – K94,999 MK95,000 - MK119,999

MK120,000 or more

If your indicated income is more than MK120,000.00 please specify the amount MK

Proof of source of Funds Payslip Bank statement Other (Specify)

Occupation Private Sector Public Sector Government Service Business Professional

Retired House Wife Student Other (Specify)

B. CONTACT DETAILS

Preferred mode of communication Email Postal

Email address

Mobile number Alternative contact number

Physical address

Town/City

Country

Proof of address Latest telephone bill (only landline) Title Documents/Tenancy or Lease agreement Latest water bill
NB: Not more than
three months old Latest electricity bill

Postal address

Town/City

Country

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Old Mutual Life Assurance Company (Malawi) Limited Malawi Savings Plan omms 12.2015 L8787
 C. BENEFIT INFORMATION

Your savings goal Education Event Dwelling General Savings (specify)

Monthly premium MK Term: 10 years

D. METHOD OF PAYMENT

Please ensure that you have completed the separate Deduction Mandate Form.

Bank Direct Order Stop Order Payroll deduction mandate Other (specify)

Worksite code Worksite name

Scheme code Scheme name

E. BENEFICIARIES
 You may nominate up to ten (10) beneficiaries on the Savings Plan. If You want to nominate more than five (5) beneficiaries, then You will be provided with an
additional beneficiary nomination form that will have to be signed by You and provided to Us with this application form. You will then be able to list
beneficiaries 6 -10 on the additional beneficiary nomination form. Both this application form and Your additional beneficiary nomination form will form a
complete list of Your beneficiaries and will be read in conjunction with one another.
 Please tick the box on Your right hand side if You have listed more than five (5) beneficiaries on this application form (below).
 Please indicate what percentage of the benefit each beneficiary should receive. The total percentage for all beneficiaries collectively on this
Savings Policy, must add up to 100%.

Title Initials First name/s Surname Gender Date of Birth ID Number Relationship to % Contacts (Phone)
policyholder
1.
2.
3.
4.
5.

F. NOMINATED GUARDIAN – Chosen only when a benefic iary is under 18 years of age.
 Proceeds will be paid to the nominated guardian ONLY where a beneficiary is under 18 years of age after the death of the policyholder and when
the proceeds are due and payable.
 If the beneficiary is older than 18 years of age when the proceeds are due and payable but there is a nominated guardian on this policy, then the proceeds
of this policy will be paid to the beneficiary and not the nominated guardian.
 All payments to the nominated guardian or the beneficiary will be in full and final settlement and discharge Old Mutual Malawi from all future liability
to third parties and in terms of this policy.

Title First name/s Surname Previous name Gender Date of Birth ID Number Guardian to Contacts
minor (Phone)
beneficiary

Marital status Married Single Divorced Widowed

Type of Identification National ID Passport Driver’s licence Voter’s card

G. POLICY REPLACEMENT
 Is this application to replace the whole or part of your existing insurance with any insurer? Yes No
 Have you stopped paying premiums or cancelled, changed or made paid-up an insurance policy in the last 4 months? Yes No

H. DECLARATION BY APPLICANT
(Tick appropriate box)
I declare that I am NOT a politically exposed person as defined as defined by the Money Laundering and Proceeds of Serious

Crime and Terrorist Financing Act, 2006

I declare that I am a politically exposed person as defined as defined by the Money Laundering and Proceeds of Serious Crime
and Terrorist Financing Act, 2006
• This Application Form signed by me has been fully completed in my presence.
• I am comfortable that this policiy satisfies my financial needs.
• My current financial position makes it possible for me to meet the monthly premium due on this Plan.
• I am a permanent resident of the Republic of Malawi.
• I am between the ages of 18 and 65 (inclusive) years of age.
• I acknowledge that Old Mutual Malawi has the right to accept or refuse my Application, which is entirely within Old Mutual Malawi’s discretion.
• I acknowledge that the policy will commence when my first premium is paid and received by Old Mutual Malawi.
• I undertake to keep Old Mutual Malawi informed of any changes to my contact information in order for Old Mutual Malawi to communicate with me.
• I acknowledge that I should seek appropriate legal, tax and investment advice prior to making any investment decisions.

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Old Mutual Life Assurance Company (Malawi) Limited Malawi Savings Plan omms 12.2015 L8787
 • I will provide all supporting documents Old Mutual Malawi may require to process my application. This will typically include proof of identification,
Premium Deduction Mandates, and proof of bank details and any other documents that might be requested.

• Please tick the correct box :

I understand and acknowledge that Old Mutual Malawi is a part of the Old Mutual Group with operations in several locations around the world.
I hereby consent to Old Mutual Malawi sharing information which I have provided with companies in the Old Mutual Group, its affiliates, service providers,
consultants and agents:
I do not consent to Old Mutual Malawi sharing information which I have provided with companies in the Old Mutual Group, its affiliates, service providers,
consultants and agents:
By signing below, I confirm that I have read this declaration and understand its implications.
Signature of Applicant Signature of Agent

Date Date
Agent initials
Agent name

Surname

Agent code Lead (Internal reference Code)

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Old Mutual Life Assurance Company (Malawi) Limited Malawi Savings Plan omms 12.2015 L8787