Proposal Form And Application Schedule (Page 2 of 2) in pdf

Proposal Form And Application Schedule Page 2

DEBIT ORDER AUTHORISATION

PREFERRED DEBIT

INCEPTION DATE

ORDER DATE

CCOUNT

OLDER

ANK

CCOUNT

UMBER

RANCH

ODE

CCOUNT

YPE

Signature of Account Holder

I/we hereby request and authorize you to draw against my/our account with the abovementioned bank (or any other

bank or branch to which I/we may transfer my/our account) the amount of *R225.00 (Two hundred and twenty five

rand only) (AMOUNT IN WORDS) or any variable amount pertaining to this agreement, on day _________ of each

month. This being the amount necessary for the settlement of the monthly premium due by you in respect of our

contract dated___________________.

All such withdrawals from my/our account by you shall be treated as though they had been signed by me/us personally.

I/we the undersigned "instruct" and authorize your agent to draw against my/our account. I/we also understand that

details of each withdrawal will be printed on my/our statement.

An administration fee of R 50 will be charged for returned debit orders. I/we agree to pay any banking charges relating

to this debit order instruction. This authority may be cancelled by means of giving you thirty days’ notice in

writing/fax/email to Memp Financial Services (Pty) Ltd, but I/we understand that I/we shall not be entitled to any

refund of amounts, which you have withdrawn whilst this authority was in force if such amounts were legally owing

to you.

I/we declare that I/we have not withheld any material information and I/we accept that this application and

declaration shall be the basis of the contract of insurance between Constantia Life & Health Assurance Co/Constantia

Insurance Co. and me/us. I/we declare that I/we understand that this application is subject to waiting periods, pre-

existing conditions and exclusions as per the Master Policy Document. I/we further declare that I/we are aware that

full details of the relevant FAIS disclosures are available from the NAPTOSA regional office and the website and Memp

Financial Services (Pty) Ltd.

Name of Principal Member

Date

Signature

Completed forms can be emailed to

napadmin@memp.co.za

or Faxed to 086 723 4635 / Queries 041 363 7333

Gap Cover insured by Constantia Insurance Company Limited/Funeral Cover insured by Constantia Life and Health Assurance Company

Proposal Form And Application Schedule Page 2