RSA

OLD MUTUAL PROTECT

DISABILITY CLAIM FORM
COMPLETED BY OWNER
Contract number

This form must be accurately completed and signed by the owner and insured person, if different.
Please email the completed form to contactus@oldmutual.com

To be completed by the adviser/admin support person if applicable.

Role: ✔ Adviser Admin support person

Surname N E M A U N G U H W I

First name(s) O L G A

Email address o n e m a u n g u h w i @ o l d m u t u a l . c o m

Contact number 0 1 5 9 6 0 2 4 5 6

Adviser code A 6 6 1 1 9 9

IMPORTANT NOTES
The premium must continue to be paid to avoid cover ending.

We can only proceed with the consideration of a claim when we receive the following documents, marked with the contract number where applicable:

Disability Claim Form completed by Owner

Disability Claim Form completed by Medical Specialist

Disability Claim Form completed by Employer

Please supply copies of supporting medical evidence as specified by the applicable event on the Disability Claim Form completed
by Medical Specialist

A certified copy of the insured person’s ID and/or owner’s ID if different

Proof of bank details, e.g. bank statement not older than 3 months

There may be further requirements before the claim can be considered, and this will depend on the type of cover concerned and the cause of the disability.
Please refer to your contract as all the conditions listed below may not be covered by your specific contract.

SECTION 1 OWNER’S DETAILS

Title: Mr Ms Mrs Other Initials

Surname/
Legal entity name

Previous surname
(if applicable)

First name(s)

Contact person

ID/Passport/Legal entity registration

Date of birth

D D M M Y Y Y Y number

Income tax number

Residential address/
Physical address of
legal entity Postal code

Nationality/Country of
birth/Legal entity
country of incorporation

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 1 Disability Claim Form by Owner (RSA) OMBDS 02.2022 C5255
 Contact details

Telephone (Work) Code No.

Telephone (Home) Code No. Cellphone number

Email address

SECTION 2 INSURED PERSON’S DETAILS (IF DIFFERENT TO THE OWNER)

Title: Mr Ms Mrs Other Initials

First name(s)

Surname

Previous surname
(if applicable)

Date of birth D D M M Y Y Y Y ID/Passport number

Residential address

Postal code

Country of residence

Contact details

Telephone (Work) Code No.

Telephone (Home) Code No. Cellphone number

Email address

SECTION 3 BENEFICIARY’S DETAILS

You may decide if you want the money to be paid to you or the named beneficiary on our records.
Please indicate who should receive the money by completing the details below.

Title: Mr Ms Mrs Other Initials

First name(s)
Surname/
Legal entity name

Previous surname
(if applicable)

Contact person

ID/Passport/Legal entity registration

Date of birth

D D M M Y Y Y Y number

Income tax number

Residential address/
Physical address of
legal entity Postal code

Nationality/Country of
birth/Legal entity
country of incorporation

Contact details

Telephone (Work) Code No.

Telephone (Home) Code No. Cellphone number

Email address

Contract number

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 2 Disability Claim Form by Owner (RSA) OMBDS 02.2022 C5255
 SECTION 4 BENEFICIARY’S BANK DETAILS
Should you be claiming for an income benefit, please indicate on which day of the month you would like to receive the monthly claim payment, should this claim

be valid

Bank name

Branch name Branch code

Name of
account holder
Account holder’s
Account number
ID number

Account holder relationship: Own account Joint account Type of account: Cheque Savings Transmission

Payment will only be done by electronic transfer. We don’t accept responsibility for delays or other damages because of incorrect information provided.

SECTION 5 MEDICAL CONDITION DETAILS

5.1 Describe the medical condition causing your disability.

5.2 State whether your disability was due to an accident or injury.

5.3 Address of police station (if any) to which the accident was reported and case number (if applicable).

5.4 Which parts of your body are affected by the medical condition?

5.5 What is the impact of the medical condition on the affected body parts?

5.6 Describe the impact of the medical condition on your ability to do the following:

Thinking clearly

Concentrating

Making decisions

Interacting with others

Walking

Sitting in a chair

Writing and typing

Reading

Operating machinery

Carrying and lifting

Driving

Feeding

Toileting

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 3 Disability Claim Form by Owner (RSA) OMBDS 02.2022 C5255
 5.7 Are there any other daily activities that are affected by your medical condition? Yes No

If “Yes”, provide full details.

SECTION 6 TREATMENT DETAILS

6.1. On what date did you first consult a medical practitioner regarding your current condition? D D M M Y Y Y Y
Provide the names and contact details of all medical practitioner and hospitals involved in your medical care, including referral dates.

Name (medical practitioner/hospital) Contact number/email address Medical condition/procedure Date Duration

6.2 When was your current condition diagnosed? D D M M Y Y Y Y

6.3 Have you previously received any medical, chiropractic or psychological attention, treatment or medication? (Excluding colds, influenza and general children’s
ailments).

If “Yes”, state the nature of the illness and give names and contact details of the doctors and hospitals consulted, including the dates of occurrence.

Name (medical practitioner/hospital) Contact number/email address Medical condition/procedure Date Duration

6.4 Are you a member of a medical aid? Yes No

Name of medical aid

Member number

Name of main member

6.5 Do you feel your condition is improving because of the treatment? Yes No

Describe in full.

6.6 Has any medical specialist given you advice or prescribed treatment for your medical condition that you have not adhered to? Yes No

If “Yes”, provide full details.

SECTION 7 EMPLOYMENT DETAILS

7.1. What was your occupation when the medical condition commenced?

7.2. Give a complete description of the duties and daily activities of your occupation or enclose a copy of your job description.

Contract number

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 4 Disability Claim Form by Owner (RSA) OMBDS 02.2022 C5255
 7.3 Please indicate the percentage of time spent/engaged in:

Administrative Manual Supervisory Travelling

% % % %

7.4 Describe how your medical condition has affected your ability to perform each of the duties and daily activities listed in 7.2 above.

7.5 When do you expect to be able to resume your current occupation?

Full capacity D D M M Y Y Y Y

Partial capacity D D M M Y Y Y Y

7.6 When last were you able to work (last date of work)? D D M M Y Y Y Y

7.7 For each occupational duty that you are no longer able to perform, please indicate when this inability began?

Occupational duty:

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

7.8 Were you engaged in any other occupation (permanent or part-time) immediately after your medical condition commenced?

If “Yes”, give details including dates below.

Name of occupation:

From D D M M Y Y Y Y To D D M M Y Y Y Y

From D D M M Y Y Y Y To D D M M Y Y Y Y

From D D M M Y Y Y Y To D D M M Y Y Y Y

From D D M M Y Y Y Y To D D M M Y Y Y Y

SECTION 8 EDUCATION, TRAINING AND WORK EXPERIENCE

8.1 Please state details (with dates) of all occupations performed by you during the past 10 years.

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

D D M M Y Y Y Y

8.2 What school, academic, professional or trade qualifications have you completed?

8.3 What alternative occupations do you consider yourself able to perform, with regard to your education, training or experience?

Contract number

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 5 Disability Claim Form by Owner (RSA) OMBDS 02.2022 C5255
 8.4 When do you expect to be able to begin the above alternative occupations?

On a full-time basis? D D M M Y Y Y Y On a part-time basis? D D M M Y Y Y Y

8.5 Give the name and address of your most recent employer.

8.6 Have you been discharged from your present occupation? Yes No

If “Yes”, provide full details.

8. 7 If self-employed, is your business being conducted on your behalf while you are unable to work? Yes No

If “Yes”, provide full details.

If “No”, which of the following duties do you still perform?

Administrative Manual Supervisory Travelling

% % % %

SECTION 9 INCOME DETAILS

9.1 P
 rovide full details of your earnings in the 12 months prior to commencement of your medical condition. Also provide details of any fluctuating income
(commission, bonuses, etc.) received in the three years prior to commencement of your medical condition.

9.2 Provide details of any income or benefit you are receiving from your pre-disability employer. Indicate for how long you expect this income or benefit to
continue.

If you answered “Yes” under question 7.8, please note full details of earnings.

9.3 Does your employer provide paid sick leave? Yes No

If “Yes”, provide full details (including the number of leave days available).

9.4 Are you currently receiving any form of disability compensation? Yes No
If “Yes”, provide details (amount, type of benefit, recurring/lump sum, company, reference number).

9.5 Is any other disability claim on your life pending or contemplated? Yes No
If “Yes”, provide details (amount, type of benefit, recurring/lump sum, company, reference number).

We may ask for additional documentation, e.g. salary slips, tax returns.

Contract number

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 6 Disability Claim Form by Owner (RSA) OMBDS 02.2022 C5255
 SECTION 10 ADDITIONAL INFORMATION

Have you travelled or resided outside the RSA in the past 12 months? Yes No

If “Yes”, provide full details including dates.

SECTION 11 OWNER/INSURED PERSON’S DECLARATION

PROTECTION OF PERSONAL INFORMATION
The Old Mutual Group would like to offer you ongoing financial services and may use your personal information to provide you with information about products or
services that may be suitable to meet your financial needs. Please sms your ID number to 30994 if you would prefer not to receive such information and/or financial
services.

The Old Mutual Group may use, share or obtain your personal information (including criminal and/or health information) for the following purposes:
• Underwriting
• Assessment and processing of claims
• Where applicable, credit reference searches or verification, credit scoring and assessment and credit management
• Verification of personal information (including your identity, address and banking details)
• Updating your personal information
• Claims checks (Industry Life & Claims Register(s)
• Tracing beneficiaries
• Debt tracing or debt recovery
• Tracing you where you are uncontactable
• Prevention and detection of fraud, crime, money laundering (including anti-money laundering screening) or other malpractice
• Market or customer satisfaction research or statistical analysis
• Audit & record keeping purposes
• Compliance with legal & regulatory requirements and in connection with legal proceedings
• Sharing information with service providers we engage to process such information on our behalf or who render services to us. These service providers may be
abroad, but we will not share your information with them unless we are satisfied that they have adequate security measures in place to protect your personal
information.

You agree that Old Mutual may view, search and update your information.

You agree that your medical information and the answers to the Health and Lifestyle questionnaire may be shared with relevant third parties (including the adviser
involved in this application). If, as a result of your health, a decision is taken to increase premiums, not to cover certain conditions or not to accept the application
for cover, you agree to the reasons for this decision being shared with the adviser. You understand that if you do not agree this application for cover will not be
processed.

You may access your personal information that we hold and may also, under certain circumstances, request us to correct any errors or to delete this information. In
certain cases you have the right to object to the processing of your personal information.

You also have the right to complain to the Information Regulator, whose contact details are:
www.justice.gov.za/inforeg/index.html
General enquiries: enquiries@inforegulator.org.za
Complaints: POPIAComplaints@inforegulator.org.za

To view our full privacy notice and to exercise your preferences, please visit our website on www.oldmutual.co.za

I/We hereby declare that the insured person is covered under the above mentioned benefit(s) and that all the particulars given are true and complete.

Date D D M M Y Y Y Y Date D D M M Y Y Y Y

Signature of owner Signature of insured person (if different to owner)

Contact us

0860 222 274

contactus@oldmutual.com

PO Box 4512, Cape Town 8000, South Africa

Contract number

Old Mutual Life Assurance Company (South Africa) Limited, Registration Number 1999/004643/06 is a licensed FSP and Life Insurer. 7 Disability Claim Form by Owner (RSA) OMBDS 02.2022 C5255