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 admin@asteronlife.co.nz,
Post Asteron Life, PO Box 894, Wellington 6140, Freepost 795
1. Direct debit authority
Payer’s details (Please use BLOCK LETTERS)
Title
Surname Given name(s)
Phone no.
Home ( )
Work ( )
Mobile ( )
Policy number(s)
Authority to accept Direct Debits
Name of account holder
Name of my bank
BANK BRANCH ACCOUNT NUMBER SUFFIX
Direct Debit/Credit Card Authority
Authorisation code
0 1 0 0 4 0 9
Approved
0040
10 2017
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.
Authorised signature
Sign here
Date
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.
12/17
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signature
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