Frequency of debit: Monthly
Termination date: Upon cancellation
Duly Authorised Beneficiary Mooirivier Specialised Brokers (Pty) Ltd
(The Beneficiary may be any
insurance party, which is
mandated or authorised to
handle short term insurance
premium collection).
Beneficiary’s Address 6A Von Pittius Street
Potchefstroom
Bank Account Reference Multid for Tenrisk
(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).