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Page 1 of 2 May 2020 Bryte Insurance Company Limited A Fairfax Company Registration number: 1965/006764/06 VAT number: 4530103581 Authorised Financial Services Provider No. 17703 15 Marshall Street, Ferreirasdorp, Johannesburg, 2001 PO Box 61489, Marshalltown 2107 Please complete this form in BLOCK CAPITALS and send it to your broker or to Bryte Insurance Company Limited. Debit Order Application Private and Confidential Please provide supporting documents if required. Name of payer (legal entity*) Policy number Physical address of payer/insured Postal Code Bank Branch name Abbreviated name as registered with the bank Branch code Account number Account type VAT registration number Company registration number Premium Date of first deduction Day of deduction every month Monthly Debit Order Authority I/We the undersigned, request and authorise Bryte Insurance Company Limited to draw against my/our nominated account the amount due for payment of the total inclusive monthly premium and any standard fees which may vary in respect of the renewable insurance policy, the instalments being adjusted as necessary in order that all amounts due shall be paid by such instalments in such manner that there is no outstanding amount due on the renewal date of such insurance policy dated ________________________________ 20_____ (“the Agreement”) on the first day/working day of each month commencing ________________________________ 20_____ and continuing until this Authority and Mandate is terminated by me/us by giving you notice in writing of not less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address as indicated above. The individual payment instructions so authorised to be issued and delivered as follows: monthly, bi-monthly, three monthly, six monthly, annually, weekly, biweekly (delete that which is not applicable). In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the very next ordinary business day. I/We understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks. I/We also understand the details of each withdrawal will be printed on my/our Bank statement. Such must contain a number, which must be included in the said payment instruction and if provided to me/us should enable me/us to identify the Agreement. This number must be added to this form in Section E before the issuing of any payment instruction. B. Mandate I/We acknowledge that all payment instructions issued by you shall be treated by my/our above-mentioned Bank as if the instructions have been issued by me/us personally. C. Cancellation I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you. D. Assignment I/We acknowledge that this Authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement this Authority and Mandate cannot be assigned to any third party. E. Agreement Reference Number This Agreement Reference number is: __________________________________________________ Furthermore, notwithstanding anything contrary contained herein or in any insurance policy, if any monthly instalment is not paid by no later than 31 (thirty one) days aſter due date for payment thereof, the insurance policy or policies in respect of which such payment was to be made shall thereupon automatically terminate without notice to myself/ourselves with immediate effect. The authorisation by me/us is made on the understanding that Bryte Insurance Company Limited will without prejudice to any of the aforegoing keep me/us advised of all amounts transferred to the debit of the facility and send me/us a monthly statement of the total amount outstanding to be paid before the next renewal date.
