(DD) #26 MDS001 – MadeSure MadeSure electronic order and agreement form Step 1 of 4 25% You are just 3 easy steps awaySign up for MadeSure easily online in under 2 minutesTo sign up for the MadeSure Protector® you will need to complete the following 3 easy steps;Employer details (responsible for payment)Employee details (beneficiary)Bank Debit info (authorize bank debit, securely, online) + eSignatureOnce complete, our administration department will load you on the MadeSure/Africa Direct system and our call-center will proceed to contact your employee (beneficiary). We are required by law to explain the policy to them in detail and collect the outstanding employee information. Step 1/3 - Employer DetailsName* First Last ID number*Please enter a value greater than or equal to 13.Tel (mobile)*Tel (work/home)Email* Postal address* Street / PO Box Suburb City State / Province / Region ZIP / Postal Code Step 2/3 - Employee DetailsName* First Last Tel (mobile)*ID numberPlease enter a value greater than or equal to 13.(not compulsory)Cover can only start on the first day of the calendar month following successful application. No requests or backdating of cover will be considered. Step 3/3 - Banking DetailsChoose a package*Protector [R95/month]Protector Plus (Includes R200 monthly Cell C airtime) [195/month]South African bank accounts onlyBank*ABSA BANKCAPITEC BANK LIMITEDFIRST NATIONAL BANKFIRSTRAND BANKINVESTEC BANK LIMITEDNEDBANKSTANDARD BANKABSA-ITHALAAFRICAN BANKALBARAKA BANKBANK OF ATHENSBANK WINDHOEK BEPERKBIDVEST BANK LIMITEDCITIBANKFBC FIDELITY BANK LTDGRINDROD BANK LIMITEDHABIB OVERSEAS BANK LIMITEDHBZ BANK LIMITEDHONGKONG & SHANGHAI BANKINGMERCANTILE BANK LIMITEDMTN BANKING(STANDARD BANK)NEDBANK LESOTHO LIMITEDNEDBANK LTD INC BOE BANKNEDBANK NAMIBIANEDBANK SWAZILAND LIMITEDPEOPLE BANK LTD INC PEP BANKPEOPLES BANK LTD INC NBSPERMANENT BANKSA POST BANK (POST OFFICE)SA BANK OF ATHENSSA RESERVESOCIETE GENERAL JHB BRANCHSOUTH AFRICAN POST OFFICESTANDARD BANK SWAZILANDSTANDARD CHARTERED BANK SASTANDARD LESOTHO BANK LTDSTATE BANK OF INDIASWAZILAND DEV AND SAVINGS BANKTHE ROYAL BANK OF SCOTLAND N.VUBANK LTDVBS MUTUAL BANKName of account holder*Branch code*Account number*Type of account*Current (Cheque)SavingsTransmissionCover will commence on the 1st of the following calendar month. Please choose the date you would like us to debit your account:Action day*1st15th20th25thLast dayof each month for the amount of:Contract amountContract amountAgreementAbbreviated short name as registered with the acquiring bank: AFRIDIRECTRefer to our contract reference number (“the Contract Reference Number”):Reference*Terms of agreementI/We hereby authorise the MadeSure administrator Africa Direct Life and Investments (Pty) Ltd (FSP no: 45834) to issue and deliver payment instructions to your banker for collection against my/our abovementioned account at my/our abovementioned bank on condition that the sum of such payment instructions will not differ from my/our obligations as agreed to in the Contract Reference. The individual payment instructions so authorised must be issued and delivered on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement. I/We agree that the first payment instruction will be issued and delivered on 27/07/2017 and thereafter regularly on the 1st of each month. If however, the date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the following business day; or subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is canceled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above. Mandate I/We acknowledge that all payment instructions issued by you shall be treated by my/our abovementioned bank as if the instructions had been issued by me/us personally. Cancellation I/We agree that although this authority and mandate may be canceled by me/us, such cancellation will not cancel the Agreement. I/we also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to you. Assignment I/We 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.General T's and C's1. In the event of any one instalment not being paid (when due) these arrangements shall terminate and cover shall deem to have lapsed on the last day of the uninterrupted period for which Monitor Administrators has received payment in terms of this request. 2. I/We agree that although this Authority and Mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We 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. 3. Should anything on the given details and information change during the period of your cover you are required to contact us within 14 days of the change. Failure to notify us of material changes can result in a delay or non-payment of your claim. 4. You are entitled to cancel this insurance giving 30 days written notice. 5. The insurer may cancel this cover if there’s non-payment of any premium, however the insurer may only cancel the cover 15 days after the required date of payment if the premium is still not received by the insurer. 6. I/We 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. We acknowledge that you utilise the services of Softy Comp for this collection. 7. The Airtime on the Protector Plus option (R195 p.m + R200) monthly airtime will be loaded automatically onto the (supplied) CellC SIM card by the 9th of the following month.I agree to the terms and conditions above* Yes Signature*Signature verified by Bank This iframe contains the logic required to handle AJAX powered Gravity Forms.