Clear form
Beneficiary form Policy/Contract number
Number of beneficiary forms for this policy/contract This form is number of
A beneficiary form is for indicating to us who must receive your investment, life cover or benefits when you pass away. We recommend that you speak to
your financial adviser before making any changes to your financial portfolio.
Important
1. Please fill in a separate form for each policy or contract number.
2. We can't record a natural person as your beneficiary if we don't receive their name, surname and date of birth.
3. It is not compulsory to give the cell phone number and email address of the beneficiary, but it will simplify any future claim process.
4. If you want to record a legal entity as a beneficiary, we need the registration documents and valid proof of identity of the authorised signatories.
5. Legislation dictates that your financial adviser must obtain certain documents to identify you. If we need any additional information we will ask you or
your financial adviser.
6. Based on the information you give us, we may ask for additional information and documents. Your financial adviser will, if necessary, refer to the
Financial Intelligence Centre Act (FICA) client due diligence checklists to let you know which documents we need.
7. The rights of a cessionary affects the rights of a nominated beneficiary. We will determine the rights of a beneficiary in line with the provisions of the
policy/contract.
8. The nominated beneficiary will become entitled to any benefits only if the beneficiary survives the insured person(s).
9. Life policies and endowments:
If the percentage of all the beneficiary nominations doesn't add up to 100%, we will pay the balance of the death value to:
• the estate of the insured person, if the policyholder/investment owner and insured person were the same natural person; or
• the policyholder/investment owner, if the policyholder/investment owner and insured person are not the same natural persons; or
• the policyholder/investment owner, if the policyholder/investment owner is a legal entity.
10. Retirement annuity:
• If you die before you retire from the Momentum Retirement Annuity Fund, the trustees of the fund must pay your fund benefit to your
beneficiaries (which include dependants and nominees) as set out in section 37C of the Pension Funds Act. The trustees must identify all your
dependants and investigate their financial dependence on you.
• They also have to consider persons who are not your dependants whom you have nominated as beneficiaries, and are referred to as nominees.
Based on this information, they will decide how to distribute the benefit between your beneficiaries and how it will be paid.
• To assist the trustees in this process, please include the details of everyone who is financially dependent on you and what percentage of your
benefit you would like each of them to receive. You may choose to allocate 0% to a person.
• You may not nominate your estate or any legal entity, and the percentage of all your nominations must add up to 100%.
11. We abide by confidentiality principles and the Protection of Personal Information Act. You voluntarily give us your consent to use your information
for the purposes of processing this instruction and related transactions and to share it with our partners and contracted service providers who are
legally bound to the same principles.
Contact person for requirements
If we cannot reach this contact person or if this section is not filled in, we will contact the client.
Name Cell phone number +27(0)
Email address
1: Policyholder/Investment owner/fund member details
Surname/Name of entity
Title Preferred name
Full names (as on RSA identity document/
passport/driving licence)
Identity/Passport/Registration number Date of birth D D M M Y Y Y Y
Cell phone number +27(0) Other +27(0)
Email address
Language preference English Afrikaans
Physical address
Postal code
Postal address (if different)
Postal code
Published: December 2023 1/3
Service007E/Beneficiary form
Policy/Contract number
2: Beneficiary details
1. Benefit number (Myriad only)
Title Initials
Full names
Surname/Name of legal entity
Relationship to policyholder/investment owner/fund member/insured person
Date of birth (compulsory if no ID number provided) D D M M Y Y Y Y Dependant Yes No
Identity/Registration/Passport number RSA ID Yes No
Cell phone number +27(0) Percentage %
Email address
2. Benefit number (Myriad only)
Title Initials
Full names
Surname/Name of legal entity
Relationship to policyholder/investment owner/fund member/insured person
Date of birth (compulsory if no ID number provided) D D M M Y Y Y Y Dependant Yes No
Identity/Registration/Passport number RSA ID Yes No
Cell phone number +27(0) Percentage %
Email address
3. Benefit number (Myriad only)
Title Initials
Full names
Surname/Name of legal entity
Relationship to policyholder/investment owner/fund member/insured person
Date of birth (compulsory if no ID number provided) D D M M Y Y Y Y Dependant Yes No
Identity/Registration/Passport number RSA ID Yes No
Cell phone number +27(0) Percentage %
Email address
4. Benefit number (Myriad only)
Title Initials
Full names
Surname/Name of legal entity
Relationship to policyholder/investment owner/fund member/insured person
Date of birth (compulsory if no ID number provided) D D M M Y Y Y Y Dependant Yes No
Identity/Registration/Passport number RSA ID Yes No
Cell phone number +27(0) Percentage %
Email address
Published: December 2023 2/3
Service007E/Beneficiary form
Policy/Contract number
5. Benefit number (Myriad only)
Title Initials
Full names
Surname/Name of legal entity
Relationship to policyholder/investment owner/fund member/insured person
Date of birth (compulsory if no ID number provided) D D M M Y Y Y Y Dependant Yes No
Identity/Registration/Passport number RSA ID Yes No
Cell phone number +27(0) Percentage %
Email address
6. Benefit number (Myriad only)
Title Initials
Full names
Surname/Name of legal entity
Relationship to policyholder/investment owner/fund member/insured person
Date of birth (compulsory if no ID number provided) D D M M Y Y Y Y Dependant Yes No
Identity/Registration/Passport number RSA ID Yes No
Cell phone number +27(0) Percentage %
Email address
3: Declaration
I/We warrant that:
1. I am/We are the legal owner(s) of the policy/contract/benefit, and competent to deal with it.
2. I/We have the right to replace this/these beneficiary(beneficiaries) with (an)other beneficiary(beneficiaries) and must give written notice of such
replacement to Momentum, a part of Momentum Metropolitan Life Limited (“Momentum”).
3. I/We agree that the nomination of a beneficiary forms part of and is subject to the declarations and documents under which you issued the policy/
contract/benefit.
4. I/We accept that the cession of the policy/contract/benefit will take precedence over the nomination of a beneficiary and I/we will read the policy/con-
tract/benefit terms if I/we consider ceding the policy/contract/benefit.
5. I/We revoke and cancel the nomination of the previous beneficiary(beneficiaries) if any.
6. I/We will keep the information of my/our beneficiary(beneficiaries) up to date.
Name and surname of authorised signatory
Capacity/Designation of authorised signatory
If I am signing on behalf of a legal entity, I confirm that I am authorised to represent the legal entity.
Signed at Date D D M M Y Y Y Y
Signature of policyholder/investment owner/fund member/duly authorised
signatory where policyholder/investment owner is not a natural person
Signature of policyholder/investment owner/fund member/duly authorised
signatory where policyholder/investment owner is not a natural person (if more
than one)
Contact details
Client contact centre
Investo - ShareCall: 0860 664 321, Telephone: +27 (0)11 505 1800, Email: [email protected]
Myriad - ShareCall: 0860 665 432, Telephone: +27 (0)11 505 1548, Email: [email protected]
Traditional - ShareCall: 0860 669 876, Telephone: +27 (0)11 505 1555, Email: [email protected]
Address: 268 West Avenue, Centurion, 0157 Postal: PO Box 7400, Centurion, 0046
Momentum Metropolitan Life Limited
Momentum is part of Momentum Metropolitan Life Limited, an authorised financial services and registered credit provider. Reg no 1904/002186/06
Refer to the company websites for directors and company secretary details momentum.co.za momentummetropolitan.co.za
Published: December 2023 3/3
Service007E/Beneficiary form
