I hereby nominate the following person, who is my dependent or nominee, for any benefits due to be paid in the event of my death.

Debit order deduction authority (Applicable to debit order payment only) I hereby authorise MR21 Funerals to commence a debit order withdrawal from my account on the debit day selected and monthly thereafter, with a possible percentage increase each year, for premium applicable for the cover selected. I understand that the debit order will be run on the date selected; if for whatever reason it is not honoured, 2(two) withdrawal runs will be submitted the next month. In the event of this run not being dishonoured, the policy will lapse, subject to the grace period as stipulated under the terms and conditions. No cash payments are acceptable for arrear or any other premiums. I understand that this signed document is required in MR21 Funerals offices 10 (ten) working days prior to the elected deduction date; if not, the deduction will only qualify for the following calendar month’s deductions, and cover will only commence the following month.

I declare to the best of my knowledge and belief that the particulars given above are true and correct. I understand and agree that any misrepresentation in this application will invalidate any benefit under this policy and that I undertake to abide by the terms and conditions of the Policy and with which I undertake to comply. The insurer shall not be liable for any amount until it has accepted first premium. I understand that I will not be covered for the months that I do not pay premiums, and that premiums are payable in advance. I further irrevocably authorize any doctor or other person who may be in possession of and/ or hereafter acquire any information concerning my health to disclose such information to the insurer and agree that this authority shall remain in force even after my death. I know and understand the contents of this declaration and I have no objection to consider it to be binding on my conscience.