Liberty Group Limited (registration no.

1957/002788/06) - an Insurer and an Authorised Financial Services Provider

(no. 2409)
Liberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001
PO Box 10499, Johannesburg, 2000
Contact Centre number: 0860 456 789 / +27 (0)11 558 4871

APPOINTMENT OF BENEFICIARY
IMPORTANT NOTES:
1. Please note that the nominated beneficiary(ies) inherit the proceeds of the policy on death of the last surviving Life Assured (this rule excludes
Lifestyle Protector policies).
2. On Lifestyle Protector policies, the Policyholder should complete a separate form for each Life Assured.
3. Please show the percentage share of benefit in which the proceeds must be distributed to each of the beneficiaries nominated.
4. Should you wish to make use of the Death Income Option, please insert the proportion to be allocated to income per beneficiary as well as the
minimum income term e.g. if 60% of the amount due will be taken as a lump sum, the remaining 40% must be inserted as the death income
portion.
Notes: - This feature only applies to the Lifestyle Protector Life Cover benefit. It does not apply to Renewable Life Cover benefit,
the Life Cover (Term) benefit or any Investment products.
- This feature will not be applicable while the policy is collaterally ceded.
5. Please provide full identity numbers of beneficiaries as this will avoid any misunderstanding at claims stage.
6. Should there be no surviving beneficiary at the date of the Life Assured’s death, the proceeds of the policy will be paid to the Policyholder of
the policy or Policyholders estate (where the Life Assured and Policyholder are different).
7. Should there be only one surviving beneficiary at the date of the Life Assured’s death, the proceeds of the policy will be payable to that
beneficiary, unless otherwise indicated.
8. Should there be more than one surviving beneficiary at the date of the Life Assured’s death, the predeceased beneficiaries’ share shall be
payable to the surviving beneficiaries in a ratio governed by their original proportions, unless otherwise indicated.
9. Death claims on retirement annuity and preservation fund policies are paid out according to the provisions stipulated in the Pension Fund Act.
Broadly speaking the trustees will pay death benefits to persons identified in terms of the procedures set by this legislation. This means that
the trustees may not necessarily pay death benefits to the people you chose as beneficiaries.
10. If you have ticked the “Trust” block below:
• The proceeds will be held in the Beneficiaries Trust Fund administered by Standard Executors and Trustees Ltd for the benefit of your
chosen beneficiary. Please note that the Beneficiary Trust Fund option does not apply to funeral, retirement annuity and preservation
fund policies.
• Whilst in trust, the trustees will make distributions for the general wellbeing, maintenance, education and advancement of the life of the
beneficiary.
• You consent that all information relating to the beneficiaries or any other information required in the administration of the Trust will be
provided by Liberty to Standard Executors and Trustees Ltd on request from time to time.
• INTERNAL NOTE: To ensure that the Trust is captured correctly please capture surname followed immediately by BTF on
Blueprint system and email this form to [email protected].
For more information you can download the deed and brochure at http://www.standardbank.co.za – then Home» Personal» Investing»
Wills drafting» Beneficiaries Trust Fund (“BTF”).
11. We are required to share, collect and process your Personal Information (PI). Your PI is collected and processed by our staff, representatives
or sub-contractors and we make every effort to protect and secure your PI. You are entitled at any time to request access to the information
Liberty has collected, processed and shared.
SEND THE COMPLETED FORM TO LIBERTY BY:
• Email: [email protected] • Post: PO Box 10499, Johannesburg, 2000

Policy number

Policyholder
Title Full first names Gender M F
Surname/Company/Trust name Maiden name
ID/Passport/Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
If company: Country of incorporation Trading name
Date of birth Place of birth Country of birth
Country of residence South African resident? Yes No
Marital status: Single Engaged Married Date of marriage
Widowed Separated Divorced Date of divorce
Email address 1
Email address 2
Contact numbers: Home Work Cell
Residential address Postal code
Postal address Postal code
Business address Postal code
Nominated occupation Industry of occupation
SA Income tax number

Please note that in the event of any modification or variation of this standard form Liberty will regard this form as being
invalid and of no force and effect. Do not sign blank or incomplete forms.
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Life Assured (if different to the Policyholder)
Title Full first names Gender M F
Surname Maiden name
ID/Passport number Date of birth
If passport: Country of issue Date of issue Date of expiry
Email address
Contact numbers: Home Work Cell
Address Postal code
Country of residence Relationship to Policyholder

Beneficiary nomination for the First Life Assured

I, ,
being the Policyholder(s) of the above policy, hereby revokes any appointment of beneficiary previously made in respect of monies payable under
the policy in the event of the Life Assured’s death, and declares and directs that, subject to the terms and conditions of the policy, such monies
shall be paid to:
First beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Second beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Third beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Fourth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

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Fifth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
Country of
If passport: Date of issue Date of expiry
issue
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Sixth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
Country of
If passport: Date of issue Date of expiry
issue
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Beneficiary nomination for the Second Life Assured

First beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to second Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Second beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to second Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Third beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to second Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

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Fourth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company Country of incorporation
Relationship to second Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Fifth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company Country of incorporation
Relationship to second Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Sixth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company Country of incorporation
Relationship to second Life Assured
Beneficiary split % Create a trust (refer to point 10 on page 1) Termination age: 18 21 25

Death Income Option for purchase of a fixed term monthly income. (Refer to point 4 on page 1)

First beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
Country of
If passport: Date of issue Date of expiry
issue
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Proportion allocated to income % Minimum income term

Second beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
Country of
If passport: Date of issue Date of expiry
issue
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Proportion allocated to income % Minimum income term

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Third beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
Country of
If passport: Date of issue Date of expiry
issue
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Proportion allocated to income % Minimum income term

Fourth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Proportion allocated to income % Minimum income term

Fifth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Proportion allocated to income % Minimum income term

Sixth beneficiary
Title Full first names Gender M F
Surname/Name of legal entity
ID/Passport/ Date of birth/
Company registration number Company registration date
If passport: Country of issue Date of issue Date of expiry
Country of residence If company: Country of incorporation
Relationship to Policyholder Relationship to Life Assured
Proportion allocated to income % Minimum income term

Note: Should you wish to make use of both the Death Income Option (on the Lifestyle Protector Life Cover benefit) and the Beneficiary Trust Fund
option for a beneficiary, the Life Cover proceeds that will be held in the Beneficiaries Trust Fund will refer only to the lump sum portion (i.e. the sum
assured less the amount allocated towards an income).

Immediate Expenses Benefit nomination (For Lifestyle Protector only)

Title Full first names Gender M F

Surname
ID/Passport number Date of birth
If passport: Country of issue Date of issue Date of expiry
Country of residence Relationship to Policyholder
Relationship to Life Assured

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*TT020506*
Signature(s)

Signed at on

Policyholder signature Policyholder signature (if more than one)

Name Name

Signed at on

Second Life Assured signature

Name

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