I hereby confirm that I am duly authorised enter into and agree to this policy. I hereby authorise and mandate Guardrisk Insurance Company Limited (Guardrisk), an authorised Financial Service Provider, to deduct monthly with effect from the premium of R from my bank account, and thereafter on the day of every following month, until such time as this authorisation in writing is cancelled, or until substituted with a new authorisation. Should the monthly selected debit order date fall on a public holiday or a weekend, I authorise Guardrisk to debit the abovementioned account on the previous working day. I further authorise Guardrisk to perform the necessary verification, validation and correction of the debit order details, supplied by me, with my bank or other third parties to ensure that the application form can be processed.

1. I warrant that all particulars on the application form are correct, whether in my handwriting or not.
2. I was advised that the Insurer will give 31 days’ notice of cancellation of this policy. I may cancel the policy effective immediately. We would like to confirm that provided premium has been collected successfully, you are covered for the full cancellation month.
3. I understand that any misrepresentation on or omission from the form may invalidate claims under the policy.
4. Notice of inflationary increases will be sent to the Insured when applicable. Failure to advice to the contrary will serve as acceptance of the new terms.
5. I warrant that there are currently no pending circumstances that could involve legal action against me, or my taking legal action against.