Personal info
Contact detail
Address
(IF APPLICABLE - NOTE: SPOUSE OLDER THAN 75 years AT THE START DATE CANNOT BE INSURED.)
(“Premium payer” - This is the person who pays the premiums and can be the policyholder or spouse covered in this policy)
I/We authorize Bokhora Funeral Catering and Deco services to draw against my / our bank account the contracted value in terms of an authority / mandate from Bokhora Funeral Catering and Deco services to collect and manage monies in respect of Bokhora Funeral Catering and Deco for which I/we extend this authority to collect by debit order. I/We further authorise Bokhora Funeral Catering and Deco services to increase or reduce such amounts due from time to time to reflect any change to the Agreement, including changes in cover risk, sum insured or premium rates, as communicated to the applicant by Bokhora. I/We understand that the withdrawals hereby authorized will be processed through a computerized system provided by the South African Banks and I/we also understand that details of each withdrawal will be printed on the bank statement, with the reference prefix “BOKHORA”. I further authorize Bokhora Funeral Catering and Deco services to deposit directly into the above account any amount which may be due to me/us in respect of any refund amounts. We shall not be entitled to any refund of amounts which Bokhora Funeral Catering and Deco services has withdrawn while this authority was in force, if such amounts were legally due. I/ We acknowledge that all debit instructions issued by Bokhora Funeral Catering and Deco services hall be treated by my/our above-mentioned bank as if the instructions had been issued by me/us personally. 1. I have received the information leaflet and summary terms and conditions containing the waiting period, rules of over insurance and the claims procedure. 2. I understand that the cover will only start when I have paid the first premium. 3. I have given all information correctly and understand that if any information is found to be untrue, my benefits may not be paid or my policy could be cancelled. I also agree to notify the underwriter in writing of any changes to the information I have provided. 4. I understand that the underwriter needs to collect and share my personal information specifically for this policy and to service, assess risks and consider claims for benefits under this policy. I also understand that this information will be kept confidential and secure for as long as the underwriter needs it. 5. I therefore authorize the staff, representatives and certain sub-contractors of the underwriter, it’s holding company and subsidiaries, to collect and process the information I have provided which is relevant to my policy and to collect, process and share such information with an appointed financial adviser or other insurer either directly through us or any other institution in the financial services industry which provides a mechanism for the transmission of personal information. 6. It is your responsibility as owner of this policy to make sure that Bokhora Funeral Catering and Deco services always has up-to-date contact information for you and anyone that can benefit on this contract. Payment details Financial Institution: First National Bank (FNB) Account Time: Cheque Branch code: 25065 Name: Bokhora (PTY) Ltd Account number: 62940583281 By accepting below, the applicant agrees to these terms and conditions.
