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Commuter Protection Plan Application Form
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Applicant Details
Title
*
Mr
Ms
Mrs
Dr
Prof
Initials
*
Surname
*
First Name
*
Known Name ( if different )
ID Number
*
Date of Birth
*
Day
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Year
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Age
*
Please enter a value between
18
and
65
.
Gender
*
Male
Female
Address
*
Street Address
Work Telephone Number
*
Home Telephone Number
Cell Number
*
Email Address
Beneficiary Details
Title
*
Mr
Ms
Mrs
Dr
Prof
Initials
*
Surname
*
First Name
*
Known Name ( if different )
Date of Birth
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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31
Month
1
2
3
4
5
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10
11
12
Year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender
*
Male
Female
Relationship
*
Contact Number
*
I have read and accept the policy terms and conditions set out below
*
Yes, I have read, understood and accept the Terms and Conditions, Addendum and Statutory Notice
Policy T's & C's
Policy T's & C's - Addendum
Policy T's & C's - Statutory Notice
Account Holder Name
*
Bank
*
ABSA
African Bank
Capitec
FNB
Nedbank
Standard Bank
Other
Please specify your bank
*
Branch
*
Branch Code
*
Account Type
*
Cheque/Current
Savings
Transmission
Account Number
*
Date of Debit Order
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I hereby authorise Evolusure to issue and deliver payment instructions to my banker for collection against my abovementioned account at my abovementioned bank on condition that the sum of such payment instructions will never exceed my obligations as agreed to in the Agreement, and commencing on and continuing until this Authority and mandate is terminated by me by giving you notice in writing of not less than 20 ordinary working days. In the event that the payment day falls on a Saturday , Sunday or recognized South African public holiday, the payment day will automatically be the very next ordinary business day. Further, if there are insufficient funds in the nominated account to meet the obligation, you are entitled to track my account and represent the instruction for the payment as soon as sufficient funds are available in my account. I understand that the withdrawals hereby authorised will be processed through a computerised system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Such must contain a number, which number must be included in the said payment instruction and if provided to you should enable you to identify the Agreement.
Do you agree to the above and acknowledge that all payment instructions issued by Evolusure shall be treated by your above mentioned bank as if the instructions had been issued by you personally?
*
Yes, I agree