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Liberty Life Capital Alliance and Liberty Active Authorised Financial Services Providers Liberty Life Centre 1 Ameshoff Street Braamfontein Johannesburg 2001 PO Box 10499 Johannesburg 2000 Contact Centres numbers Liberty Life 0860 456 789 Capital Alliance - 0860 991 991 Liberty Active - 0860 102 013 PORTFOLIO SWITCH REQUEST IMPORTANT NOTES Please complete this form and forward to Liberty Life at the above address. Tax ref. no. I being the owner s of the above contract hereby revoke any portfolio switch previously made and declare and direct that subject to the terms and conditions of the contract and Liberty Life s practice at the time the portfolios should be changed as follows please print. Note Specific portfolios apply to specific policy types. CURRENT PORTFOLIO S the portfolio s in which the current contribution s are invested FROM Name of Portfolio TO Split FUTURE PORTFOLIO S the portfolio s in which all future contribution s will be invested Note Only complete if you are to make future contributions. Note Phasing is only allowed at inception. Signed at on this day of OWNER S SIGNATURE Address to which letter of confirmation must be sent Postal code Must this address be used for all future correspondence YES NO 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 PS01 07/2009. An acknowledgement will be sent to you shortly hereafter. If you select more than one portfolio please show the proportion in which funds must be distributed* Policy Number Owner s Cessionary if applicable Telephone No* h w E-Mail Address Cell No* ID/Passport no. Tax ref* no. I being the owner s of the above contract hereby revoke any portfolio switch previously made and declare and direct that subject to the terms and conditions of the contract and Liberty Life s practice at the time the portfolios should be changed as follows please print. Note Specific portfolios apply to specific policy types. CURRENT PORTFOLIO S the portfolio s in which the current contribution s are invested FROM Name of Portfolio TO Split FUTURE PORTFOLIO S the portfolio s in which all future contribution s will be invested Note Only complete if you are to make future contributions. Note Phasing is only allowed at inception* Signed at on this day of OWNER S SIGNATURE Address to which letter of confirmation must be sent Postal code Must this address be used for all future correspondence YES NO 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 PS01 07/2009. An acknowledgement will be sent to you shortly hereafter. If you select more than one portfolio please show the proportion in which funds must be distributed* Policy Number Owner s Cessionary if applicable Telephone No* h w E-Mail Address Cell No* ID/Passport no. Tax ref* no. I being the owner s of the above contract hereby revoke any portfolio switch previously made and declare and direct that subject to the terms and conditions of the contract and Liberty Life s practice at the time the portfolios should be changed as follows please print.

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