Debit Order Authorisation

Name of Account Holder

Address of Account Holder

Name of Bank

Branch Code

Account Number

Type of Account

Current/Cheque

Savings

Transmission

Payment Amount

(This amount may vary each month due to a) annual

increase b) costs incurred where debit orders are returned

unpaid c) changes that you make to the Agreement, or other

additional amounts due on an ad hoc basis, allowed and

specified in the Agreement.)

Payment Date

Your account can be debited on the 1ste to the 15th of the month.

Important Information

Frequency of debit:

Monthly

Termination date:

Upon cancellation or lapse of the

Agreement.

Duly Authorised Beneficiary (The Beneficiary may be any

insurance party, which is mandated or authorised to handle short term insurance premium collection).

Mooirivier Makelaars Potchefstroom (EDMS)

Bpk.

Beneficiary’s Address

11 Walter Sisulu Avenue

Potchefstroom

Bank Account Reference

(The bank account reference will reflect on your monthly bank

statement to enable you to identify the Debit Order and will be

added to this form before the issuing of any payment

instruction. This reference may only be changed upon 31 days

written notice).

Multid for Tenrisk

Mandate

Covered Property Address

Complex Name & Unit Number

This signed mandate and authority relates to the insurance contract (referred to as “the Agreement”) agreed by

you for the above mentioned property. This mandate

shall remain in force until cancelled by giving 31 (thirty-one) days’ notice in writing to Mooirivier Makelaars

Potchefstroom (EDMS) Bpk. and/or its authorised agents and/or cessionary. Cancellation of this mandate does

not cancel the Agreement.

Authority

I hereby authorise Infiniti Insurance Ltd and/or its authorised agents and/or cessionary to draw against

my account detailed above (or any other Bank to which I may transfer my account) the amount necessary

for payment of the amount payable by myself in terms of the Agreement. acknowledge that a third

party may facilitate the payment process and debit my account on behalf of Infiniti Insurance Ltd.

I acknowledge that a third

party may facilitate the payment process and debit my account on behalf of Infiniti Insurance Ltd. I

confirm that the amount debited from my account may be paid to an insurer/s (by the beneficiary) for

insurance cover.

I acknowledge that all payment instructions issued by Infiniti Insurance and Mooirivier Makelaars

Potchefstroom (EDMS) Bpk. and/or its authorised agents, and/or cessionary shall be treated by my

above-mentioned Bank as if the instruction has been issued by me.

I agree that the first payment instruction will be issued and delivered on or around the Payment Date,

and regularly thereafter, until the termination date, and according to the Agreement. Each individual

payment instruction may not differ other than as agreed to in terms of the Agreement. In the event that

the payment day falls on a weekend, or recognised South African public holiday, the payment day will

automatically be the very next ordinary business day.

I acknowledge and consent that this authority may be ceded or assigned to a third party if the Agreement

is also ceded or assigned to that third party, and I am notified accordingly.

Signature 1

Signature field is empty.

Signature (Account Holder)

Signature 2

Signature field is empty.

Signature (For Corporate clients, if two signatures are required)