Broker Appointment & Debit Order Authorisation

1. Act on my/our behalf in all matters related to the initiation, servicing, amendment, and claims handling of the policy.

2. Act on my/our behalf in all matters related to the initiation, servicing, amendment, and claims handling of the policy.

3. Communicate directly with the insurer on my/our behalf, including the receipt and delivery of documentation.

4. Provide me/us with policy advice, premium updates, and risk management support relevant to the Labour Insure product.

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I/We understand and confirm that:

1. This appointment does not preclude me/us from appointing another broker in the future but remains in effect unless revoked in writing.

2. Mooirivier Specialised Brokers (Pty) Ltd acts in accordance with the Financial Advisory and Intermediary Services Act (FAIS) and is a registered financial services provider.

3. All information submitted to the broker will be treated as confidential and processed in line with POPIA (Protection of Personal Information Act).

 I understand that CLRS@ease is a separate labour advice service paid for out of the monthly collection, that its recommendations are non binding legal opinions (not underwriting decisions), and that my chosen labour representative remains responsible for formal representation.

I acknowledge that this signed mandate and authority relates to the insurance contract (referred to as “the Agreement”) agreed to by

myself. This mandate

shall remain in force until cancelled by giving 31 (thirty-one) days’ notice in writing to Mooirivier Specialised Brokers (Pty) Ltd. and/or its authorised agents and/or cessionary. Cancellation of this mandate does not cancel the Insurance Agreement.

I hereby authorise Infiniti Insurance Ltd and/or its authorised agents and/or cessionary to draw against

my account detailed above (or any other Bank to which I may transfer my account) the amount necessary

for payment of the amount payable by myself in terms of the Agreement.

I acknowledge that a third

party may facilitate the payment process and debit my account on behalf of Infiniti Insurance Ltd. I

confirm that the amount debited from my account may be paid to an insurer/s (by the beneficiary) for

insurance cover.

I acknowledge that all payment instructions issued by Infiniti Insurance and Mooirivier Specialised Brokers and/or its authorised agents, and/or cessionary shall be treated by my

above-mentioned Bank as if the instruction has been issued by me.

I agree that the first payment instruction will be issued and delivered on or around the Payment Date,

and regularly thereafter, until the termination date, and according to the Agreement. Each individual

payment instruction may not differ other than as agreed to in terms of the Agreement. In the event that

the payment day falls on a weekend, or recognised South African public holiday, the payment day will

automatically be the very next ordinary business day.

I acknowledge and consent that this authority may be ceded or assigned to a third party if the Agreement

is also ceded or assigned to that third party, and I am notified accordingly.