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Debit Order Authorisation

Type of Account
Current/Cheque
Savings
Transmission

Important Information

Frequency of debit:

Monthly

Termination date:

Upon cancellation or lapse of the

Agreement.

Duly Authorised Beneficiary (The Beneficiary may be any

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

Mooirivier Makelaars Potchefstroom (EDMS)

Bpk.

Beneficiary’s Address

11 Walter Sisulu Avenue

Potchefstroom

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).

Multid for Tenrisk

Mandate

This signed mandate and authority relates to the insurance contract (referred to as “the 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 Makelaars

Potchefstroom (EDMS) Bpk. and/or its authorised agents and/or cessionary. Cancellation of this mandate does

not cancel the Agreement.

Authority

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