DEBIT ORDER AUTHORITY

Full Name of Assured:

Nominated Bank: Account Holder: Bank Name: Branch: Branch Code (6 digit): Account No: Account Type:

Details of my/our Bank Account are as follows:-

Current/Cheque

Transmission

Savings

I/We instruct and authorise Tradeforth 6 (Pty) Limited trading as Abelard Underwriting Agency (the Underwriting Agents) on behalf of Underwriters to draw against my/our account with the abovementioned Bank (or any other Bank or Branch to which I/we may transfer my/our account) the monthly Premiums relating thereto (which Premium and Fees may change from time to time) due in respect of the insurance contracts effected through the Underwriting Agents to the benefit of the Assured named above. All such withdrawals from my/our bank Account by the Underwriting Agents shall be treated as though they had been signed by me/us personally. This authority may be cancelled by me/us by giving thirty days notice in writing, sent by prepaid registered post, to the Underwriting Agents, it being understood and agreed that I/we shall not be entitled to any refund of amounts which the Underwriting Agents may have withdrawn during the currency of this Authority if such amounts were legally owing to the Underwriting Agents and/or their Underwriters. All Instalments will be deducted on the first working day of each month, unless otherwise agreed by the Underwriting Agents in writing. Receipt of this instruction by the Underwriting Agents shall be regarded as receipt thereof by my/our Bank. Signed at on this _____ day of

Signature of the Assureds authorised representative: Capacity of the Assureds authorised representative: Witness:
Tradeforth 6 (Pty) Ltd trading as Abelard Underwriting Agency (Reg No 1996/008912/07) Manor House, 6 Conrad Drive, Blairgowrie, 2194 P.O. Box 2155 Pinegowrie 2123, Tel +27 11 326-2951, Local Fax 0866 351 124 International Fax +27 (011) 326 2952 Web Site www.aua.co.za Directors: D J C Cox (Managing), C E Diederiks, C P Norrington (British), K L Waugh F.A.I.S Compliance Details FSP Licence Number: 28 Compliance Practice: Intelligent Compliance and Education (Pty) Limited FSB Practice No: 554 Compliance Officer: Peter Veal