Section 6 – Domestic assistant

	Surname and name	Gender (tick option)	Relation
1		Male Female
2		Male Female
3		Male Female
4		Male Female

Section 7 – Terms and conditions

I acknowledge:

- that I have read and understood the terms and conditions of this contract (attach terms and conditions of the policy) – Refer to attached document

- that I have taken note of the statutory notice to Long-term insurance policyholders (attach statutory notice to Long-term insurance policyholders) – Refer to attached document

Section 8 – Declaration by the policyholder/applicant

As the principal member, I hereby acknowledge that the declaration detailed below is binding on the life/lives assured and I declare to the best of my knowledge and belief that the particulars given in this form are true and correct. I understand and agree that any willful misrepresentation in this application will invalidate any claim to the benefit and I furthermore undertake to abide by the terms and conditions of this policy. Safrican Insurance Company Limited, as underwriter of this policy, shall not be liable for any amount until this application has been accepted and my monthly premiums payable are up to date. I confirm that this application form has not, neither has part thereof, been completed by anyone representing or purporting to represent me as the principal member.

I hereby authorise Safrican Insurance Company Limited (Safrican) to commence debit order withdrawals/deductions from my account on (tick appropriate day of month)

1st

20th

25th

of 20 for the amount of
R ; and monthly thereafter with a possible percentage increase each year, for the premium applicable for the cover selected. I/We understand that the debit order will run on the date selected, if for whatever reason it is not honoured, two withdrawal runs will be submitted the next month. In the event of this run being dishonoured the policy will lapse. I understand that this signed document is required in Safrican’s offices, 10 (ten) working days prior to the elected deduction date, if not, the deduction will only qualify for the following calendar month’s deductions. Safrican may vary the debit order collection date where necessary due to public holidays and other reasons deemed necessary at the time of collection.

All such withdrawals from my bank account by Safrican shall be treated as though they had been signed by me personally. I understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and also understand that details of each withdrawal will be printed on my bank statement. I agree to pay any bank charges relating to the debit order instruction.

I understand that the party hereby authorised to effect the drawing(s) against my/our account may not cede or assign any of its rights to any third party without my prior written consent and that I may not delegate any of my obligations in terms of this contract/authority to any third party without prior written consent of the authorised party.