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Benefit Option

Payment Option
EFTDebit Order Once-OffDebit Order Monthly

I/We authorise Genesis Insurance Brokers (Pty) Ltd. and/or their collection agents to draw against my/our account when the premium(s) is due for the policy and/or any substituted policy(ies) to which I/we extend this authority. I/We understand and agree that if any premium(s) is/are not met by the bank referred to below when the debit order is presented, the policy(ies) is/are cancelled automatically. This authority remains in force until cancelled in writing by me/us or the Company.

ITOO and Genesis care about your privacy. In order to provide you with our service, we and our service providers have to process the personal information you provide us with by completing this form. We will treat this information with caution and we have put reasonable security measures in place to protect it.

Referral

I acknowledge that the sharing of insurance information for underwriting and claims purposes (including credit information) between insurers is in the public interest as it enables insurers to underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims with a view to limiting premiums. On my own behalf and on the behalf of any person I represent herein, I hereby waive my right to privacy with regard to underwriting or claims information (including credit information) that I provide or that is provided by another person on my behalf in respect of any insurance policy or claim made or lodged by me. I acknowledge that the insurance information provided by me may be stored in the shared database and used as set out above as well as for any decision pertaining to the continuance of my policy or the meeting of any claims I may submit. I consent to such information being disclosed to any other insurance company or its agent. I acknowledge that the information may be verified against legally recognized sources or databases. I AGREE THAT this proposal shall be the basis of the contract between the insurer and myself. I WILL ACCEPT the insurer’s standard policy. I UNDERSTAND that this insurance will not commence until this proposal has been accepted by the insurer.