Order Number Cover Details Policy Type * Protector - Monthly Debit R 70 Individual - Monthly Debit R 130 Family - Monthly Debit R 160 Business Silver - Monthly Debit R 300 Business Gold - Monthly Debit R 410 Personal Details Title Adv Mr Mrs Mr & Mrs Miss Dr Prof Revd Revd Dr Revd Adv Revd Canon The RT Revd The Very Revd The Most Revd The Ven The Hon Ds Past Ms Messerd Estate Late Surname ID Number Gender Male Female Occupation Telephone: Home Language First Name Date of Birth Marital Status Single Married Divorced Widow/Widower Email Telephone: Work Nationality Postal Address Physical Address Banking Details Account Holder Name Type of Account * Cheque Saving Bank Branch Account Number Branch Code Declaration (Please read) I hereby apply for Legal Cost Insurance on the Policy Terms and Conditions. I understand that the Policy will incept upon payment of the first Premium. I acknowledge that the payment of Premiums on the due dates is my responsibility. I understand that if the debit date falls on a weekend or public holiday, it will be raised on the previous or next business day. I hereby authorise the Insurer and its agent(s) to debit my bank account, with amounts due until cancellation of the Policy. I authorise my bank to treat these payment instructions as if issued by me personally. I undertake to notify the Insurer of any changes to my particulars. I authorise the Insurer and its business partners to access and use of my personal information. I choose the above as my address for service of legal documents. I hereby declare that I am an authorised signatory of the bank account above. I understand that the Legal cost of any Legal Proceeding arising from an Insured Event which occured before the Date of Cover will not be covered. I confirm that I have read this declaration, understand its contents and implications and personally signed it. Accept Declaration * Yes No Date *