Direct Debit Form

TOWER Insurance Direct Debit Authority
Not to operate as an assignment or agreement
Policy numbers
To the Bank Manager Details to appear on my/our bank statement

Please print full postal address clearly for use in a window envelope Your client and/or policy reference will appear on your bank
Bank name statement should you need to make an enquiry.
Branch Authorisation
Postal address I/We, the Customer, authorise you, the Bank, until further notice in
Suburb writing to debit my/our bank account with all amounts which TOWER
Limited (the Initiator), the registered initiator of the authorisation code
Town/City
below, may initiate by the direct debit system. I/We acknowledge and
Postcode accept that the Bank accepts this authority only upon the conditions
My/our account details listed in this form.
Customer name Authorised signature(s)
Name of account holder
Account number Date
Bank Branch number Account number Suffix
To be paid: Monthly Quarterly Half-yearly Annually Authorisation code 0 3 1 8 7 0 5

Please attach an encoded deposit slip for your bank account.
Conditions of this Authority to accept Direct Debits

1 The Initiator: 3 The Customer acknowledges that:
(a) Undertakes to give notice to the A cceptor of the commencement date, frequency and (a) This A uthority will remain in full force and effect in respect of all Direct Debits passed to
amount at least 10 calendar days before the first Direct Debit is drawn (but no more than my/our account in good faith notwithstanding my/our death, bankruptcy or other revocation
2 calendar months). This notice will be provided either: of this Authority until actual notice of such event is received by the Bank.
(i) in writing; or (b) In any event this Authority is subject to any arrangement now or hereafter existing between
(ii) by electronic mail where the Customer has provided prior written consent to the Initiator me/us and the Bank in relation to my/our account.
Where the Direct Debit system is used for the collection of payments which are regular as (c) Any dispute as to the correctness or validity of an amount debited to my/our account shall
to frequency, but variable as to amounts the Initiator undertakes to provide the A cceptor not be the concern of the Bank except in so far as the Direct Debit has not been paid in
with a schedule detailing each payment amount and each payment date. accordance with this Authority. Any other disputes lie between me/us and the Initiator.
In the event of any subsequent change to the frequency or amount of the Direct Debits, the (d) Where the Bank has used reasonable care and skill in acting in accordance with this
Initiator has agreed to give advance notice of at least 30 days before changes come into Authority, the Bank accepts no responsibility or liability in respect of:
effect. This notice must be provided either: the accuracy of information about Direct Debits on Bank statements
(i) in writing; or any variations between notices given by the Initiator and the amounts of Direct Debits
(ii) by electronic mail where the Customer has provided prior written consent to the Initiator (e) The Bank is not responsible for, or under any liability in respect of the Initiators failure to
(b) May, upon the relationship which gave rise to this Authority being terminated, give notice to give written advance notice correctly nor for the non-receipt or late receipt of notice by me/
the Bank that no further Direct Debits are to be initiated under the Authority. Upon receipt of us for any reason whatsoever. In any such situation the dispute lies between me/us and
such notice the Bank may terminate this Authority as to future payments by notice in writing the Initiator.
to me/us. (f) Notice given by the Initiator in terms of clause 1(a) to the debtor responsible for the
2 The Customer may: payment shall be effective. Any communication necessary because the debtor responsible
(a) A t any time, terminate this A uthority as to future payments by giving written notice of for payment is a person other than me/us is a matter between me/us and the debtor
termination to the Bank and to the Initiator. concerned.
(b) Stop payment of any Direct Debit to be initiated under this Authority by the Initiator by giving 4 The Bank may:
written notice to the Bank prior to the Direct Debit being paid by the Bank. (a) In its absolute discretion conclusively determine the order of priority payment by it of any
(c) Where a variation to the amount agreed between the Initiator and the Customer from time monies pursuant to this or any other authority, cheque or draft properly executed by the
to time to be direct debited has been made without notice being given in terms of 1(a) Customer and given to or drawn on the Bank.
above, request the Bank to reverse or alter any such Direct Debit initiated by the Initiator by (b) A t any time terminate this A uthority as to future payments by notice in writing to the
debiting the amount of the reversal or alteration of the Direct Debit back to the Initiator Customer.
through the Initiators Bank, PROVIDED such request is made not more than 120 days from (c) Charge its current fees for this service in force from time-to-time.
the date when the Direct Debit was debited to my/our account.
TOWER use only STB
Client number Policy number
BANK USE ONLY

TIDDFORM 06/10
Date Received: Received By: Checked By:

Approved
1870
BANK STAMP
06 10
Please return completed form to: TOWER Insurance Limited, PO Box 90347, Victoria Street West, Auckland 1142

Direct Debit Form

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TOWER Insurance Direct Debit Authority

Not to operate as an assignment or agreement

To the Bank Manager Details to appear on my/our bank statement

Customer name Authorised signature(s)

Name of account holder

Account number Date

Bank Branch number Account number Suffix

To be paid: Monthly Quarterly Half-yearly Annually Authorisation code 0 3 1 8 7 0 5

Conditions of this Authority to accept Direct Debits

TOWER use only STB

Client number Policy number

BANK USE ONLY

Date Received: Received By: Checked By:

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