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day of the month (add an appropriate day of the month), and monthly thereafter for the premium applicable for the cover selected. I understand that the debit order will be run on the date selected. If for any reason it is not honoured, two withdrawal runs will be done the next month. In the event of this second run being dishonoured, the Policy will lapse. I understand it is required that this application form reaches Phakama offices 10 working days prior to the selected deduction date, if not, the deduction will only qualify for the following calendar month’s deductions. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment will automatically be the preceding ordinary business day. Should the relevant premium rate be adjusted by the insurer as a result of an inflation related increase in the premium rate, I confirm that the adjusted premium rate may be deducted. I agree that although this Authority and Mandate may be cancelled by me by giving written notice of 31 (thirty-one) days, such cancellation will not cancel the Agreement unless expressly stated by myself. I shall not be entitled to any refund of amounts which you have withdrawn while this Authority was in force, if such amounts were legally owing to you. I acknowledge and agree that payment instructions issued from this Mandate will be treated as payment instructions issued personally by myself, the account holder. I acknowledge that this authority may be ceded or assigned to a third party if the Agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party. The User Abbreviated Name as Registered with the Bank will reflect as follows on your bank account: LIFEHERO followed by your policy / membership number.

If you are paying on behalf of the Principal insured, please ONLY sign this section below.

The Financial Intelligence Centre Act (FICA) requires that we know if you are an influential person as explained in the Act. It differentiates between a politically exposed person, domestic prominent influential person, foreign prominent public official and a known close associate or family of domestic prominent influential persons and foreign prominent public officials. More than one of the definitions can apply to the same person. Read the explanations at the end of this form, indicate which explanations apply to you and give your reason.

DEFINITIONS OF INFLUENTIAL PERSONS

A Politically exposed person is someone who is or has been entrusted with prominent public functions, based on a specific political affiliation. Examples: A head of state, cabinet minister, member of parliament/local/provincial government, senior administrator in government department (financial department/tender processes), senior judge, manager of local municipalities who award tenders, senior and/or influential official, ambassador/high commissioner, senior representative of a religious organisation.

• A Prominent influential person refers to any individual who is or has in the past been entrusted with prominent functions in a particular country. A South African PIP would be known as a Domestic PIP. A Foreign Prominent Public Official (FPPO) would be someone who holds a Prominent Public Official (PPO) position in a foreign country. Examples: Premier of a province, member of a foreign royal family, government minister or equivalent senior politician, leader of a political party, high ranking member of the military/police, etc.

• A known close associate is an individual who is closely connected to a prominent person, either socially or professionally. The term “close associate” is not intended to capture every person who has been associated with a prominent person. Examples: Known relationships outside the family unit (e.g. girlfriends, boyfriends, mistresses), a prominent member of the same political party, civil organisation, labour or employee union as the prominent person, business partner or associate, especially one who shares (beneficial) ownership of corporate vehicles with the prominent person, or who is otherwise connected (e.g. through joint membership of a company board), any individual who has sole beneficial ownership of a corporate vehicle set up for the actual benefit of the prominent person.

• A family member is an individual who is related to a PEP/PIP either directly (consanguinity) or through marriage or similar (civil) forms of partnership. Examples: Spouse or civil/life partner, previous spouse or civil/life partner, children and stepchildren and their spouses or civil/life partners, parents, siblings and stepsiblings and their spouses or civil/life partners.

FOR COMPLETION BY THE ADMINISTRATOR FICA CONFIRMATION

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