Fillable Application for With-Prot Annuity (Law for All South Africa)

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Application for With-Prot Annuity (Law for All South Africa)

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The Application for With-Prot Annuity (Law for All South Africa) form is 3 pages long and contains:

  • 4 signatures
  • 19 check-boxes
  • 96 other fields

Country of origin: SOUTH-AFRICA
File type: PDF

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1
Application for With-Prot Annuity
2. Second life
First name/s
Surname
Date of birth
Title
Initials
D D - M M - Y Y Y Y
(Compulsory purchase only)
NOTE: Ensure that all sections are completed in full, each page initialed and declaration signed
ANN0011220E
Address Line 1
(eg PO Box or Private Bag)
1. Personal details of first life
First name/s
Surname
Date of birth
Member title
Initials
D D - M M - Y Y Y Y
Male Female
Married Single
Marital status
Gender
RSA ID
ID/Passport No.
Country of issue of Passport
Yes
No
Income tax reference No.
Telephone No. (H) (C)
Income tax ofce
Postal Address
Address Line 2
Address Line 3
Address Line 4
Residential address
Unit no.
Street number
Suburb
City / Town
Country
E-mail address
Postal code:
Postal code:
Complex
Street / Farm name
Divorced Widowed
As above
Our default method of communication to our annuitants is email. Where no email address is available, we will post all correspondence.
Relation to 1st life
Yes
No
Client Initial
corporate
RSA ID
ID/Passport No.
Country of issue of Passport
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signature
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2
5. Annuitant payment details
6. Declaration
I, the undersigned hereby apply for an annuity as described above, with MMI Group Limited, the underwriting insurer.
I declare and warrant that the information in this application, whether in my handwriting or not, is true, correct and complete and will form the basis of the
proposed contract between myself and Momentum.
Signature of Applicant
Date
D D - M M - 2 0 Y Y
Branch no.
Account type
Name of bank
Branch name
Account number
Savings, cheque, etc
Name of account holder
4. Beneficiary(ies) details
Name of beneciary Date of birth Relationship Percentage
%
%
%
%
%
3. Annuity details
Date of retirement
Investment amount
Gross monthly annuity
Annuity type
or
R
R
D D - M M - 2 0 Y Y
Commencement date
Increase month
Golden Growth With-Prot
Golden Income With-Prot
Golden Growth WPA – Performer Life
Golden Income WPA – Performer Life
Single life
Joint life
Post-Retirement Interest Rate (PRI)
Guarantee period (in months)
Commission sacriced (%)
Spouse’s reversion % (on death of 1st life)
Member reversion % (on death of 2nd life)
Client Initial
D D - M M - 2 0 Y Y
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signature
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signature
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3
9. Investment Annuities banking details
10. Annuities Contact Details
Name of bank
Branch name
Type of account
Account No.
Branch code
Name of account holder
F N B
G e n e r i c
C h e q u e
6 2 5 0 7 0 0 5 7 0 1
2 5 5 0 0 5
MMI Group Limited – Annuities – EBI
REF: Use as Reference Client Surname
Annuity Operations: New Business Implementations
Momentum Corporate
PO Box 2212, Bellville, 7535.
Fax: +27 (21) 940 6600
E-mail:EBAnnuityImplementat@momentum.co.za
Annuity Operations: Complaints
Momentum Corporate
PO Box 2212, Bellville, 7535.
Fax: +27 (21) 940 6603
E-mail: EBAnnuitiesComplaint@momentum.co.za
7. Intermediary details
8. Brokerage banking details (please attach formal proof of bank details)
External Consultant
Momentum Internal Consultant
Broker representative name
Broker House name
Broker representative code
Broker House code
Name
VAT registration No.
Commision No.
Commission
Yes
No
(If Yes complete sections 7&8)
Branch no.
Account type
Name of bank
Branch name
Account number
Savings, cheque, etc
Name of account holder
Client Initial
Momentum Metropolitan Life Limited Parc du Cap 4 Mispel Road Bellville 7530 PO Box 2212 Bellville 7535 South Africa
Tel +27 (21) 940 5386 - EBAnnuityImplementat@momentum.co.za - www.momentum.co.za/ebcorporate
Momentum Corporate is a part of Momentum Metropolitan Life Limited, an authorised nancial services and registered credit provider.
Licence 6406
Sales channel
Sales channel region
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signature
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Application for With-Prot Annuity (Law for All South Africa)

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Completed 8 July 2021

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