UNIT LINKED POLICIES

REQUEST FOR WITHDRAWAL

OR SURRENDER OR MATURITY
This form should only be used to request a partial, full surrender or maturity
from an Old Mutual International unit linked policy.

BEFORE COMPLETING AND SUBMITTING THIS FORM YOU SHOULD:

– Speak to your financial adviser to ensure you are following the most suitable course of action for your circumstances
– Refer to your policy terms and literature
– R ead the guidance notes on taking money from your policy available on our website www.oldmutualinternational.com or by
contacting us
–B
 e fully aware of the possible tax consequences that may apply on taking money from your unit linked policy – this is particularly
important for UK residents
– If surrendering your unit linked policy, request a approximate calculation of the surrender value as early encashment charges
may apply.

To help you, we have used an arrow u to highlight certain facts and to let you know that you can find further information and
explanations in the guidance notes available on our website or by contacting us.
There are a number of alternatives to surrendering part or all of your policy and before making a decision you may wish to consider
reviewing the investments you hold or read the document ‘are you sure surrendering is the best option?’, available on our website. This
could give you the opportunity to achieve one or more of the following:
• better performance
• less risk
• stable returns.
It is important to review your policies regularly because:
• the investment market can change quickly
• your attitude to risk may change.

To complete this form:

– use CAPITAL LETTERS only
– use blue or black ink
– specify choices as appropriate
– complete all relevant sections; refer to the guidance notes where relevant
– do not use correction fluid; any amendments should be crossed out and initialled by all policyholders.
Please return the completed form(s) in original, and any title or other documentation where applicable, to:
The Unit Linked policy Claims Department, Old Mutual International Isle of Man Limited, King Edward Bay House, King Edward Road,
Onchan, Isle of Man IM99 1NU, British Isles
Fax: +44 (0)1624 611 715
Tel: +44 (0)1624 655 555
Unit Linked policy queries contact: rskfmulpsclaims@ominternational.com
 a Details of the policy from which payment will be made
uPlease see the guidance notes on how to complete this section.

Policy number
- Type of investor (3) Individual Trustee Corporate
(for example MCA 12345678)

Details of Trustee policyholder

The trust name is The trust

(for example ‘the John Brown was created
D D M M Y Y Y Y
Will Trust’)

Details of Corporate policyholder

Corporate name

Details of individual policyholder(s)

If there are any further policyholders, please photocopy this page, attach the details with this form and tick here. (3)

Policyholder 1 Policyholder 2 (if any)

Title (3) Mr Mrs Miss Mr Mrs Miss

Other Other

Full forename(s)

Surname

Policyholder(s) address (Trustee, Corporate and individual)

Residential address
(where you are currently living)

Postcode Postcode
Daytime telephone
number including dialling
code
E-mail address

Fax number

Financial adviser details

Financial adviser Financial advisers

company name
Financial adviser Financial adviser
contact number e-mail address

Third party details

If third party/pledge interest exists, please ensure that we have an up to date signatory list. If this has not already been provided, please also include ID
and proof of residency of two directors which must be certified as true.
Full name(s) of Pledgee(s)

Addresses of Pledgee(s)

Postcode Postcode

Page 2 of 9
 b Type of encashment

uPlease see the guidance notes for information about the different options.

Please tick here if you have taken professional advice on the best way of cashing in your policy, taking your present tax status into account. (3)

Please indicate below which type of encashment you would like (Please tick one option only): (3)

• Full surrender of all policies

• Maturity of all policies (note: payment cannot be made until maturity date of the policy has
been reached)
• Identical part surrenders to all policies to release a total sum (withdrawal) Amount

• Full surrender of individual policy segment(s) 

Enter a range, for example ‘1 to 5’, or choose a value for which Old Mutual International will calculate the appropriate number of policies for surrender.
We will encash whole policies as close to the value needed, and then we will partially encash the remaining policies to achieve your requested amount.

Range to OR Value

Regular withdrawals – (only available on MCA and EWA policy)

uThis section to be completed if you wish to make a regular withdrawal by way of a partial surrender from your policy. Please see guidance notes for
more information.

Please indicate the amount or percentage of your premium(s) to be withdrawn each year (the minimum level of payment is £500 or currency equivalent)
Amount (per annum) OR Percentage of premiums
paid in (per annum)

Please choose the frequency of the withdrawal (3) Monthly Quarterly Half-yearly Yearly

Date of first withdrawal

D D M M Y Y Y Y

continued

Page 3 of 9
 c Payment details

uPlease see the payment details section of the guidance notes before completing this part of the form.
Please make sure this section is completed in clear BLOCK CAPITALS. If your payment is being sent in Sterling to a UK bank this does not involve a bank
charge. If payment is not in Sterling or to a bank outside of the UK a bank charge will apply.

Bank details of policyholder

Bank name

Bank address

Country Postcode

Payee name

Payee account
number/ IBAN

Sort code Branch code for

- -
(applicable to UK accounts only) non-UK payments

ABA number
SWIFT/BIC code
(SWIFT code needed for bank accounts outside Europe; BIC code needed for European accounts with an IBAN)

Currency of the bank

account payment being
made to
Additional information
that may be required by
the bank

If payment is to be split equally between joint policyholders, please complete these details on page 6 and tick here (3)

For Old Mutual International use only Policy number

Payment details

Template number Currency Amount (figures)

Date Payment type NatWest charges Foreign bank charges

Client/OMI Client/OMI

JDE code or Orion reference Amount Narrative

Raised by Authorised Signed (Fin only)

Additional information

continued
Page 4 of 9
 c Payment details — for second policyholder (if applicable)

uPlease see the payment details section of the guidance notes before completing this part of the form.
Please make sure this section is completed in clear BLOCK CAPITALS. If your payment is being sent in Sterling to a UK bank this does not involve a bank
charge. If payment is not in Sterling or to a bank outside of the UK a bank charge will apply.

Bank details of policyholder

Bank name

Bank address

Country Postcode

Payee name

Payee account
number/ IBAN

Sort code Branch code for

- -
(applicable to UK accounts only) non-UK payments

ABA number
SWIFT/BIC code
(SWIFT code needed for bank accounts outside Europe; BIC code needed for European accounts with an IBAN)

Currency of the bank

account payment being
made to
Additional information
that may be required by
the bank

For Old Mutual International use only Policy number

Payment details

Template number Currency Amount (figures)

Date Payment type NatWest charges Foreign bank charges

Client/OMI Client/OMI

JDE code or Orion reference Amount Narrative

Raised by Authorised Signed (Fin only)

Additional information

Page 5 of 9
 d Authority of policyholder(s) requesting the payment

u SIGNATORIES – all policyholders, including additional trustees and/or assignees where applicable, must sign below. Please indicate the capacity
in which you are acting.
The undersigned as policyholder (each policyholder if the policy is owned jointly) hereby:
1. authorise and request Old Mutual International to carry out the transaction detailed in Section B in accordance (where applicable) with
Old Mutual International’s Terms and Conditions.
2. confirms that all the information contained in the document is true and correct and that they are entitled to the legal and/or beneficial interest in
the policy unless the policy is subject to a trust and the beneficiaries are entitled to receive payment in accordance with the trust provisions.
3. confirm that there is no Bankruptcy Order against the policyholder or beneficiary nor are they an undischarged bankrupt or deemed to be insolvent
under any relevant insolvency legislation.
4. undertakes to indemnify Old Mutual International against any claims or demands made by any other person or party as a result of the payment
requested in Section B.
5. agrees that payment of the the partial or full surrender proceeds or maturity benefit shall constitute full discharge of the liability of
Old Mutual International.
6. confirms of fully/partially encashing your policy or taking the maturity benefit from your policy (if applicable) you have read and understood the
guidance notes attached to this form, have sought and considered financial advice in regards to the potential tax consequences and have referred
to your policy terms and literature.
uOld Mutual International does not offer legal, tax or financial advice and we can accept no responsibility for any action taken or refrained from on
the basis of information provided by us. Any information provided is based on our understanding of the current law and practice and is subject to
change in the future.
Signatory 1

Signed Date

D D M M Y Y Y Y

Full name

Capacity (3) Individual Trustee Pledgee Other

Signatory 2

Signed Date

D D M M Y Y Y Y

Full name

Capacity (3) Individual Trustee Pledgee Other

Signatory 3

Signed Date

D D M M Y Y Y Y

Full name

Capacity (3) Individual Trustee Pledgee Other

Signatory 4

Signed Date

D D M M Y Y Y Y

Full name

Capacity (3) Individual Trustee Pledgee Other

Page 6 of 9
 e Checklist
Fully completed form in original

If fully surrendering your policy you must cancel any standing order you have in place to fund your policy

Current photo ID plus proof of residential address certified by financial adviser, if suitable certifier, otherwise notary public/solicitor
(if this has not already been provided)

Proof of address must be no more than three months old, ID must be valid and in date (mobile phone bills are not acceptable)

f Feedback questions – for Full Surrender of all policies only

At Old Mutual International we are keen to improve our products and services. To help with this, we would value your feedback. Could you please spend
a few moments completing the questions below to help us understand why you have decided to cash in your Old Mutual International policy.

1. Did you seek advice from a financial adviser? (3) Yes No

2. What is the main reason for deciding to cash in your policy? (3)

Poor fund performance

Premiums/charges too high or not what you expected

Poor customer service experience

To invest in a different product with Old Mutual International

Product not what you expected (eg lack of flexibility)

Monies required for another purpose (eg to buy a house)

No specific reason

Product acheived my financial needs/expectation

Purchase an alternative product with another provider

3. If you intend to invest the payment from this encashment with another product provider, please confirm with whom.

4. Can you confirm if you are a UK resident for tax purposes?

If so, what type of taxpayer are you? (3) (tick on right for answer) Non taxpayer
This information is purely for marketing purposes. Basic rate

Higher rate

Additional rate
Thank you for completing these questions.

www.oldmutualinternational.com
Calls may be monitored and recorded for training purposes and to avoid misunderstandings.
Old Mutual International Isle of Man Limited is registered in the Isle of Man under number 24916C. Registered and Head Office: King Edward Bay House,
King Edward Road, Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0)1624 655 555 Fax: +44 (0)1624 611 715.
Authorised and regulated by the Isle of Man Insurance & Pensions Authority.
Old Mutual International Isle of Man Limited is a member of the Association of International Life Offices.
Old Mutual International is registered in the Isle of Man as a business name of Old Mutual International Isle of Man Limited.

PDF7845/INT11-228R/March 2012
Page 7 of 9
GUIDANCE NOTES
Important information on policy proceeds and payment

The following will define the type of policy you hold with Old Mutual International:
• Unit Linked policies – All references to ‘Unit Linked policies’ in this document means your regular premium contract which include, but are not restricted
to, your Managed Capital Account, Managed Capital Bond, Managed Savings Account, Managed Savings Bond, Managed Pension Account,
Managed Pension Bond and Executive Wealth Account.
When encashing or making one-off withdrawals, it’s important to consider that:
• You may have to pay tax if you withdraw or surrender or take the maturity proceeds from your policy. Therefore we strongly recommend you consult
with your financial adviser before completing this form.
• You may incur early encashment charges. Therefore we strongly recommend you ask for an approximate calculation of the surrender value before
completing this form.
• You may incur set up costs if you move your investments to a new provider.
How can we send you the policy proceeds?
• Payments will be made in the currency in which the policy is denominated.
• If you ask for the payment to be sent to the beneficiary/benficiaries of a trust you should be aware of the following:
–– If the trustees are UK/Hong Kong resident then payments to UK/Hong Kong resident beneficiary/benficiaries are limited to a total of
£50,000 (or currency equivalent) in any policy year.
–– We will require certified ID and proof of the residential address of the beneficiary/ies, if not already provided, in order to prevent delays
in processing the payment.
–– UK/Hong Kong payments exceeding the £50,000 limit must be made to a trust bank account.
–– Old Mutual International reserves the right to cancel payments if they exceed the £50,000 limit.
–– Payments will only be made to an account at a UK/Hong Kong financial institution held in the name of the UK/Hong Kong resident
beneficiary/benficiaries.
–– For all other trusts, payment must always be payable to the trust bank account.
• No third party payments are allowed.
• If you are taking a part surrender, full surrender of individual policy segment(s) or regular withdrawal, a surrender value of £1,000
(or currency equivalent) must remain in the policy.
When you are ready to request a payment, what should you do?
• Please return the completed form(s) in original, and any title or other documentation where applicable, to:
The Unit Linked policy Claims Department, Old Mutual International Isle of Man Limited, King Edward Bay House,
King Edward Road, Onchan, Isle of Man IM99 1NU, British Isles
Fax: +44 (0)1624 611 715
Unit Linked policy queries contact: rskulpsclaims@ominternational.com

a Details of the policy from which payment will be made

In this section you should enter the policy number from which you wish the payment to be made. Please confirm whether this is a request from an
individual, trustee or corporate policyholder by ticking the relevant field. If the policyholder is a trust please fill out the name of the trust and the date
that it was created. If the policy is in the name of a corporate investor please enter the corporate name in the space provided. If the policyholder is
an individual(s) please enter full name in the space provided. You then need to give the full address details of policyholder(s).

Financial adviser details

Please complete the company name, individual name, contact number, fax number and e-mail address of your financial adviser.

Third party details

Please give the name of any third party to whom the policy has been pledged or with whom the policy schedules may have been deposited or otherwise
charged as security. If this applies please also ensure that section D is also signed by the third party.

b Type of encashment
In this section please choose the currency in which you would like your payment to be received (if you choose a currency which is not the currency of
your policy, currency dealing charges may apply).
Please choose the type of encashment that you require from the options:
• Full surrender of all policies
This is the sale of all investments into the policy currency and the encashment of all policies.
• Identical part surrenders to all policies to release a sum (withdrawal)
This is to request a specific amount by cashing in an equal amount across all policies.
• Full surrender of individual policy segment(s)
This is the full surrender of a specific policy segment(s).
• Maturity of all policies
This is the sale of all investments into the policy currency and the maturity of all policies now you have reached the end of the policy term or your
selected retirement date.

Page 8 of 9
 b Type of encashment (continued)

Regular withdrawals
The minimum monthly payment is £500 (or equivalent).
• If payment is in Sterling to a UK bank account this does not involve a bank charge and can take up to three working days to reach
your account once paid. Payments not in Sterling or being paid to a bank outside of the UK will incur a bank charge.
• Percentages withdrawn will be based on the premium(s) received prior to this request. If you require the percentage to include any
additional funds received in the future, we will require revised instructions to this effect at that time.

In all circumstances we suggest that you seek financial and tax advice before submitting any request for
payment to ensure you are aware of any tax consequences as a result of the encashment from your policy.

c Payment details

• Payments will only be made to a bank account in the policyholder’s name; we will not accept requests to make payments to third
parties.
• In exceptional circumstances payments can be made to financial institutions, financial advisers/solicitors/accountants which are
recognised by the UK Financial Conduct Authority (FCA), and who have the appropriate authorisation to handle client money.
Please discuss such requests with Old Mutual International before submitting your form.
• Payment will be sent to your bank account by telegraphic transfer and bank charges will be incurred.
• For joint policies, payment will be made to both policyholders, either in full to a joint bank account or split equally to bank accounts
in each of the policyholders’ names (please use section C to provide the second policyholder’s bank details if applicable).
• All payments on corporate policies will be made payable to the company.
• All payments to banks within Europe require a BIC/SWIFT and an IBAN. Please ensure that these fields are filled in as it may delay
your payment without this information.
If proceeds are to be split equally between joint policyholders, please ensure that the tick box is filled and give details of the second
policyholder in the area provided.

d Authority of policyholder(s) requesting the payment

All policyholders, including additional trustees and/or assignees where applicable, must sign this section. Please also indicate the
capacity in which you are acting. These signatures authorise and request Old Mutual International to effect the transaction(s) detailed
on this form.
By signing this form you confirm that you have read and understood policy terms and conditions and guidance notes on making
a payment from the policy.

e Checklist

This is to ensure that you have included all the information needed for us to process your request. Please tick the corresponding fields
to make certain that the necessary documents have been supplied.

f Feedback questions

In order for us to continuously improve our products and services we appreciate any feedback that we receive. Please answer these
questions and if you have any other comments or suggestions, you can contact us at the address at the beginning of these guidance
notes, or use the e-mail addresses provided.

If there are any further questions then please visit

www.oldmutualinternational.com/FAQs/Old-Mutual-International

www.oldmutualinternational.com
Calls may be monitored and recorded for training purposes and to avoid misunderstandings.
Old Mutual International Isle of Man Limited is registered in the Isle of Man under number 24916C. Registered and Head Office: King Edward Bay House, King Edward Road,
Onchan, Isle of Man, IM99 1NU, British Isles. Phone: +44 (0)1624 655 555 Fax: +44 (0)1624 611 715.
Authorised and regulated by the Isle of Man Insurance & Pensions Authority.
Old Mutual International Isle of Man Limited is a member of the Association of International Life Offices.
Old Mutual International is registered in the Isle of Man as a business name of Old Mutual International Isle of Man Limited.

PDF7845/INT11-228R/March 2012
Page 9 of 9