OLD MUTUAL PROTECT

BANK DEDUCTION MANDATE

PO Box 4512, Cape Town, 8000, South Africa.
Tel 0860 222 274.
Mutualpark, Jan Smuts Drive, Pinelands 7405. South Africa

TH MR THAMSANQA HLENGWA, 50

PERSONAL INFORMATION
Title Mr

Last name Hlengwa

First name Thamsanqa

Identity number 7402126078089

BANK ACCOUNT DETAILS

Name of bank accountholder HLENGWA

Name of bank Capitec Bank Bank account type Current

470010 Bank account 0000001245499716

Bank branch code
number

First premium due date 2024-06-30 Premium frequency Monthly Future premium 30
deduction date

Mandate reference 0000AD4C2B Collection amount R 356 108347849/ R 356

Q000015021867

Bank statement reference 0000AD4C2B

BANK DEDUCTION MANDATE

I give Old Mutual permission to arrange for the payment of the premiums with my bank. I understand that the premium will be
deducted on the day that I have chosen or on my salary payment date where Old Mutual is able to get this information. I
understand that I have agreed to pay the starting premium and any contractual increases to it over the term of the contract. I
understand that up to two outstanding premiums may be included in these deductions. I understand that any premiums for an
Old Mutual product will show on my bank statement as 0000AD4C2B.

I further understand that, if Old Mutual is unable to collect my premium on the date that I have chosen or on my salary payment
date because there was not enough money in my account, Old Mutual, with the help of my bank, will track my account and deduct
my premiums when there is enough money in my account. I understand that any premiums for an Old Mutual product will show
on my bank statement as 0000AD4C2B.

SIGNATURE

Name: Mr Thamsanqa Hlengwa, 50

Mobile number: (+27) 0784701724
Electronic signature received 2024-05-13 at 10:23:54

Unique code: 8265510150421510834784991

I understand and accept that the unique code above links my signature to this document.

Application number 108347849 Unique code: 8265510150421510834784991 Page 1 of 1