I hereby authorise you to issue and deliver payment instructions to your banker for collection against my abovementioned
account at my above-mentioned bank (or any other bank or branch to which I may transfer my account)
on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the
agreement and commencing on the date of debit order above and continuing until this authority and mandate
is terminated by me by giving you notice in writing of not less than 30 days and sent electronically or by post to
the address as indicated above. The individual payment instructions so authorised to be issued must be issued and
delivered MONTHLY. In the event that the payment day falls on a Sunday, or a recognised South African public holiday,
the payment day will automatically be the very next ordinary business day. I understand that the withdrawals hereby
authorised will be processed through a computerised system provided by South African banks. I also understand
the details of each withdrawal will be printed on my Bank statement and will contain a number that enables me to
identify the agreement.
I acknowledge that all payment instructions issued by you shall be treated by my bank as if the instructions have been
issued by me personally.
I agree that although this authority and mandate may be cancelled by me, such cancellation will not cancel the
agreement. I shall not be entitled to any refund of amounts which you have withdrawn while this authority was in
force, if such amounts were legally owing to you.
I acknowledge that this authority may be ceded or assigned to a third party if the agreement is also ceded or assigned
to that third party, but in the absence of such assignment of the agreement this authority and mandate cannot be
assigned to any third party.
I furthermore agree to advise Medway of any changes to the above banking details.
I accept this declaration
1. I have explained the meaning of the replacement of an insurance policy to the
applicant policy owner.
2. I am a representative of an Authorised Financial Services Provider in terms of the Financial
Advisory and Intermediary Services Act, 37 of 2002 and confirm that the applicant policy
holder has been provided with all information required in terms of the Act.
3. I declare that I am accredited to sell these Medway products, that I did
conduct a financial needs analysis and that this product is designed to fulfil
the applicant’s needs.
4. I further declare that all the information contained in this application was obtained
from the applicant and was completed and signed in his/her presence.
Click here to read the Statutory Disclosure