How to ﬁll in this authority
1. If you would like to pay your premium by Direct Debit from your bank account please complete section 1.
2. If you would like to pay your insurance premium by credit card please complete section 2.
3. Please state your preferred method of communication in section 3.
Print, complete and sign this form. Return to us by: Email firstname.lastname@example.org,
Post Asteron Life, PO Box 894, Wellington 6140, Freepost 795
1. Direct debit authority
Payer’s details (Please use BLOCK LETTERS)
Surname Given name(s)
Home ( )
Work ( )
Mobile ( )
Authority to accept Direct Debits
Name of account holder
Name of my bank
BANK BRANCH ACCOUNT NUMBER SUFFIX
Direct Debit/Credit Card Authority
0 1 0 0 4 0 9
From the acceptor (you) to your bank:
I authorise you to debit my account with the amounts of direct debits from Asteron Life Limited with the authorisation code speciﬁed on this authority
in accordance with this authority until further notice.
I agree that this authority is subject to:
• The bank’s terms and conditions that relate to my account, and
• The speciﬁc terms and conditions listed below.
Speciﬁc direct debit conditions relating to notices and disputes
Asteron Life is required to give written conﬁrmation of the amount and date of each direct debit in a series of direct debits no later than the date of the ﬁrst
direct debit. The conﬁrmation is to include:
• the dates of the debits, and
• the amount of each direct debit.
I may ask my bank to reverse a direct debit up to 120 calendar days after the debit if:
• I don’t receive a written conﬁrmation of the amount and date of each direct debit from Asteron Life, or
• I receive a written notice but the amount or the date of debiting is different from the amount or the date speciﬁed on the notice.
If I’m not reasonably satisﬁed that the authority authorised my bank to debit my account with the amount of the direct debit, I may ask my bank to reverse
a direct debit up to 9 months after the date Asteron Life sent the ﬁrst direct debit under the authority.
If the bank dishonours a direct debit but Asteron Life sends the direct debit again within 5 business days of the dishonour, Asteron Life is not required
to give notice of the amount and date of the second direct debit.
If Asteron Life proposes to change an amount or date of a direct debit speciﬁed in the conﬁrmation, they are required to give notice:
• no less than 30 calendar days before the change, or
• if Asteron Life’s bank agrees, no less than 10 calendar days before the change.
I understand I can contact Asteron Life at any time and cancel or change this payment authority.
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