DEBIT ORDER AUTHORITY FORM
   
INSURED

 
Name:    
Postal Address:    
Cell: Telephone No:
Fax No: Email Address:
Insurance Co. : Policy No:
   
DEBIT ORDER AUTHORITY
Name of bank:
Branch:
Account Holder:
Branch Code:
Type of account:
Account number:
   
DECLARATION
I hereby authorise Compendium Insurance Group to draw against the above account (or any other Bank or Building Society
to which I may transfer my account) the amount necessary for payment of the premium and renewal premiums due to various
Insurance Companies in respect of my insurances.

The amount of my debit may vary from time to time to refl ect any changes in cover, risk, sum insured or premium rates.

I agree that in the event of any debit order not being met by my Bank/Building Society, the policy will be cancelled and will be of
no effect from midnight on the last day of that month for which Compendium Insurance Group has received payment.

This authority may be cancelled by me giving Compendium Insurance Group 30 days notice in writing, but I understand that I
shall not be entitled to any refund of amount which Compendium Insurance Group have drawn while this authority was in force
if such amounts were legally owing to various Insurance Companies.

Receipt of this instruction by Compendium Insurance Group shall be regarded as receipt by my bank or building society.
   
Signature: