Debit Order Form

I/We

authorise and/or their collection agents (the Company) to draw against my/our account when the premium(s) due for the policy(ies) listed below and/or any substituted policy(ies) to which I/we extend this authority.

I/We further authorise the Company to vary such premium due from time to time to reflect any change in cover, risk, sum insured or policy rates.

I/We understand and agree that if any premium(s) is/are not met by the bank referred to below when the debit order is presented, the policy(ies) is/are cancelled automatically from the end of the period of insurance for which premium has been paid.

This authority remains in force until cancelled in writing by me/us or the Company.

I further authorise

and/or their collection agents to deposit directly into the above account any amount which may be due to me/us either in respect of any refund premiums or in settlement of any claim.

I/We understand that the withdrawals from the above account will be processed through a computer system and that the details of each withdrawal will be printed on my bank statement.

KEU, Centriq and Genesis care about your privacy. In order to provide you with our service, we and our service providers have to process the personal information you provide us with by completing this form. We will treat this information with caution and we have put reasonable security measures in place to protect it.