It is understood that the policy is issued in the name of the Agency and not in the name of any landlord.*

It is understood that premium is paid by the Agency and the Agency does not collect premium on behalf of the landlord.*

I hereby confirm that I have received the policy wording of the two TENRISK financial products.*

That I unconditionally agree to inform the Mooirivier Brokers immediately of any changes in the information supplied which are relevant to the policy to be issued.*

I am aware that, a comprehensive needs assessment cannot be undertaken (due to the nature of the product).*

I must consider whether this product I chose is appropriate pertaining to my goals, circumstances, and needs.*

I completed this application out of free will.*

I understand by submitting this document it is a legal and binding document*

I confirm that when I apply my signature hereunder that I am authorised to do so as the legal representative of the Agency.*

I confirm that when I apply my signature hereunder that I am authorised to do so as the legal representative of the Agency.*

I acknowledge that this signed mandate and authority relates to the insurance contract (referred to as “the Agreement”) agreed to by myself for the forementioned property. This mandate shall remain in force until cancelled by giving 31 (thirty-one) days’ notice in writing to Mooirivier Specialised Brokers (Pty) Ltd. and/or its authorised agents and/or cessionary. Cancellation of this mandate does not cancel the Insurance Agreement.*

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. *

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 Specialised Brokers 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.*

1. Act on my/our behalf in all matters related to the initiation, servicing, amendment, and claims handling of the policy.

2. Act on my/our behalf in all matters related to the initiation, servicing, amendment, and claims handling of the policy.

3. Communicate directly with the insurer on my/our behalf, including the receipt and delivery of documentation.

4. Provide me/us with policy advice, premium updates, and risk management support relevant to the Tenrisk product.is a checkbox.

I/We understand and confirm that:

1. This appointment does not preclude me/us from appointing another broker in the future but remains in effect unless revoked in writing.

2. Mooirivier Specialised Brokers (Pty) Ltd acts in accordance with the Financial Advisory and Intermediary Services Act (FAIS) and is a registered financial services provider.

3. All information submitted to the broker will be treated as confidential and processed in line with POPIA (Protection of Personal InformationThis is a checkbox.