AVBOB
AVBOB MUTUAL ASSURANCE SOCIETY
368 Madiba Street, Pretoria, 0002
PO Box 1661, Pretoria, 0001
Tel: 0861 28 26 21
Email:
[email protected]AVBOB Mutual Assurance Society is an authorised financial services provider
APPLICATION FOR SURRENDER OF POLICY/SAVINGS PLAN
POLICY DETAILS
POLICY NUMBER Policy Savings plan
Initials and surname of the assured Date of birth
YYYYMMDD
CONDITIONS, DECLARATIONS AND RESTRICTIONS
(1) I/We wish to apply for payment of the surrender value
Savings plan amount (Nett) Policy amount (Nett)
R R
(2) I/We understand and agree that:
• All amounts due to AVBOB regarding this policy will be deducted from the surrender value.
• Payment of the said amount will only be effected on receipt of all required documents.
(3) I/We further declare that:
3.1 I/We am/are the legal owner(s) of the policy and am/are legally competent to dispose of the policy;
3.2 I/We have not ceded or pledged the policy to anyone, either by ante nuptial contract or otherwise;
3.3 My/Our estate(s) is/are solvent and has/have not been surrendered, sequestrated or assigned.
(4) Will this policy be replaced by another policy (Tick in applicable box) Yes No
If yes, state the name of the assurer:
SIGNED AT THIS DAY OF 20 YY
SIGNATURE OF POLICYHOLDER
Postal address Postal code
ASSISTED BY (Name and surname of parent or legal guardian if the signatory is a minor)
Tel no Cell no
Email
08/18 0064
IDENTIFICATION
This identification must be completed by an AVBOB Administrative Officer or a Commissioner of Oaths.
I, declare that
appeared before me
and that his/her identity number/date of birth is
Branch code Branch name
SIGNED AT THIS DAY OF 20 YY
SIGNATURE OF PERSON WHO IDENTIFIES
PAYMENT DETAILS
(1) Please credit my/our bank account below:
Account number Name of bank
Branch code Branch name
City/town Type of account
Savings Transmission Cheque
(2) (a) Cheque will be collected from AVBOB office at
(b) Please forward a cheque for the nett amount to me at the following address Postal code
(c) Electronic transfer - if the necessary requirements have been supplied and the bank can provide such facility.
SIGNATURE OF ACCOUNT HOLDER
I/We confirm that the correct details are reflected above
(3) We must, however, also bring the following to your attention:
(a) You and any person(s) co-assured, if applicable, lose the value cover and any additional benefits offered
under the policy.
(b) Only the surrender value of the policy (less any debt against the policy) is payable and not all
premiums paid.
(c) We may reduce the value of your savings plan if you end (surrender) it before the end of the agreed term
of the policy, during a period of difficult financial market conditions. This is called applying a Market Value
Adjustment (MVA) and is done in terms of our Principles and Practices of Financial Management (PPFM)
– a document that explains the way that we manage our products and bonus declarations.
(d) The termination of any policy and replacing it with another policy is generally contrary to your interest as
there is a duplication of costs once for your existing policy and again for any new policy, which you might
consider applying for.
08/18 0064
(e) As a result of the increase in your age you may pay a higher premium than the premium under your
surrendered policy with possible exclusions or restrictions should there have been deterioration
in your health status.
(f) If your policy with the Society is being terminated as a result of a replacement with a policy with another
Assurer you are entitled to:
i. Enjoy a “cooling-off” period of 30 days by the new Assurer, in terms of which you may decide
whether or not to proceed with the new policy, without any cost involved to yourself; and
ii. Have a “Replacement Policy Advice Record” completed by the Intermediary who marketed
(or will market) the new policy to you in which he/she has to explain the consequences of
termination of your policy with us and the benefits under the new policy, so as to enable you to make
a fully informed decision on your actions.
(g) Current policy values for Assured
Assured amount R
Vesting bonus R
Non-vesting bonus R
Total R
*In addition to the policy value, policyholder benefits are applicable
SURRENDER DECLARATION: PLEASE READ THE FOLLOWING BEFORE SIGNING
Herewith I
(Full names(s) and surname)
ID number Policy number
YES NO
1. I am voluntarily surrendering my policy
2. I was coerced/forced/advised to surrender my current policy in order to replace it with another
3. I understand by surrendering this policy I and/or any other insureds on my policy will not
have funeral cover and that a claim in respect of a death will not be paid out
4. I understand that by surrendering this policy all bonuses and values will be lost
5. I understand that I will not be refunded in full on my premiums thus far
6. I understand that if I do replace my current policy with a new policy, my premiums could
be more or less cover and that I will have a new waiting period for six months should
death occur as a result of natural causes
7. I understand that by replacing my old policy, cost on my policy will be duplicated
Reason for surrender
SIGNATURE OF POLICYHOLDER SIGNATURE OF AREA MANAGER
08/18 0064
