Broker Appointment &
Debit Order Authorisation

Name of Account Holder

Address of Account Holder

Email of Account Holder

Name of Bank

Branch Code

Account Number

(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.)

Important Information

Frequency of debit:

Termination date:

Duly Authorised Beneficiary (The
Beneficiary may be any

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

Monthly

Upon cancellation

Mooirivier Specialised Brokers (Pty) Ltd

Beneficiary’s Address

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).

6A Von Pittius Street

Potchefstroom

MULTID FORINFINITI

Mandate

Address of Rental Property

Enter complex name and unit number

Authority

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.

Broker Appointment

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.

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 Information Act).

Signature (Account Holder)

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

Broker Appointment & Debit Order Authorisation