DIRECT DEBIT FORM

NAME OF POLICY HOLDER

Title: (*)

Surname: (*)

First Name: (*)

Policy Number:

Phone Number: (*)

Product: (*)

Email Address: (*)

BANK ACCOUNT DETAILS (please tick as appropriate)

Bank Name: (*)

BVN: (*)

Account No: (*)

Account Name:

Title: (*)

Surname: (*)

First Name: (*)

Middle Name: (*)

Frequency of Savings Contribution Payment: (*)AnnualSemi-AnnuallyQuarterlyMonthly

I/We hereby request and authorize you to draw against my/our account with the above-mentioned bank (or a bank to which I/We may transfer my/our account) the sum or such sums may be revised:

Amount in Figures: (*)

Amount in Words: (*)

I understand and undertake that United Bank for Africa (UBA), the authorized service provider for Heirs Life Assurance Limited, will receive all amounts without prejudice. I/We confirm that the debit order authorization has been signed in terms of the mandates held by my/our bank and I/We agree to pay any bank charges relating to this debit order/instruction.

My preferred date of deduction is on the (e.g. 2, 10, 28, etc.)(*) day of every(*)

Direct Debit Commencement Date: (*)

I hereby request and authorize any branch of my bank to certify that the particulars of this mandate is correct.

Customer's Signature: (*)

Date: (*)