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APPLICATION FOR GROUP POLICY

Choose the entity of the agency
Sole proprietor
Partnership
Company
Close Corporation
Business Trust

Debit Order Information

Type of Account
Current/Cheque
Savings
Transmission
Choose your monthly premium

(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 Insurance Agreement, or other additional amounts due on an ad hoc basis, allowed and specified in the Insurance Agreement.)

Choose your payment date

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

Declarations

Carefully read through the following declarations and click the checkbox to confirm the statement. (These declarations are required, and you will not be able to submit the application if they are not all selected)

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Important Information

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).

Mandate

This number was povided by Tenrisk Management

This signed mandate and authority relates to the insurance contract (referred to as “the Insurance 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 Specialised Brokers (Pty) Ltd. and/or its authorised agents and/or cessionary. Cancellation of this mandate does not cancel the Insurance Agreement.

Authority

Broker Appointment

I hereby appoint Mooirivier Specialised Brokers FSP No. 54431 as my/our authorised insurance broker for the purposes of administering and managing my/our Tenrisk Rental and Eviction Cover policy/ies.

This appointment authorises Mooirivier Specialised Brokers (Pty) Ltd to:

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