Bank
Account Type
Cheque Savings
Term
Monthly Annual
Debit Order Date
1st 4th 7th 15th 20th 25th 28th Last day of the month
*
Optional
(Increments of R 10)
R
Total Monthly Premium
R
Account Holder Signature
By signing this section, you:
1. authorise Stratum Benefits to debit your account for the policy premium that is payable in advance, on the debit order date as selected.
2. authorise Stratum Benefits to accept this debit order authority as a payment instruction issued by the account holder.
3. accept that depending on the selected debit order date, a double debit may be incurred.
agree that this debit order authority will remain in force until cancelled in writing by the principal insured person, or by Stratum Benefits if premiums are not received for two
consecutive months.
5. understand that this debit order authority may only be assigned to a third party if this contract is also assigned to a third party.
6. understand that if your payment date falls on a Sunday, or recognised South African public holiday, the debit order date will default to the next working day.
7. understand that cover will commence after the first premium is received.
accept that if the premium from a previous debit order deduction is returned, a
admin fee will be added to the next premium deduction.
accept that your premium may be adjusted during an annual renewal or due to benefit restructuring necessitated by legislation with one month’s written notice, and subject
to your right of cancellation of cover, the debit order authority will extend to the adjusted premium.
10. understand that your debit order deductions will be processed through a computerised system provided by the South African Banks. Details of each debit order deduction
will be displayed on your bank statement with the reference prefix "STRATUM" followed by an 8 digit number ending with "SAGEPAY".
11. accept that given the debit order authority granted by you, it is your responsibility to ensure that premiums are collected in order to remain covered.
accept that you shall not be entitled to any refund of amounts which have been deducted while this debit order authority is in force, if such amounts were legally due.
13. understand that the product premium is inclusive of VAT.
5. DECLARATION ACCEPTANCE
As the principal insured, I hereby declare that all the information provided is true and correct. I accept that any non-disclosure or misrepresentation may render my
Principal Insured Signature
Date
New Brokerage New Broker
Please provide the details of the new broker that you are appointing to advise you on your Gap Cover policy.
*
If you want to add an additional professional fee to your monthly Stratum Benefits policy premium, which will be paid to your appointed broker on a recurring basis over and
above the monthly commission amount, please indicate the amount below.
GAP COVER PROFILE UPDATE FORM
Physical/Postal
Postal Code
Title
Surname
ID/Passport
Name
Please select the appropriate type of update applicable to your request.
Change your debit order details as indicated in Section 4
Appoint a new broker to advise you on your Gap Cover policy as indicated in
Section 3
Email yoursupport@stratumbenefits.co.za for any other update request not mentioned below, such as adding and/or removing a dependant, option change, etc.
Email
Please enquire
if you have not received feedback within 7 days from submitting your Amendment Form.
t 086 111 3499 w
stratumbenefits.co.za
Please complete the fields below to ensure that we have your most up to date information.
Principal Insured Signature
Professional Fee
(Increments of R10)
R
Total Monthly Premium
R
2. MAIN APPLICANT DETAILS
4. CHANGE DEBIT ORDER DETAILS
7046093818
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