A – CONTRACT DETAILS Scheme Name: MyLife ™ Member No: ML Category: Cover Amount: R Entry Date: Cover Date: Total Premium: Risk Premium: Marketing/Admin Fee: B – MAIN MEMBER DETAILS Surname: Full Names: Title : ID: Date of Birth: Address: code: Email: Contact Number: Preferred Language: EnglishAfrikaansXhosa C – SPOUSE DETAILS Surname: Full Names: ID: Date of Birth: Relationship: MarriedLiving Together BENEFICIARY DETAILS Name & Surname: Relationship: ID: Telephone: DECLARATION BY APPLICANT I declare that neither I nor my dependents suffer from any pre-existing health conditions that could lead to an early death. I understand and accept waiting periods, premiums and other conditions in the master policy as explained to me by the Intermediary. D – CHILDREN DETAILS Child 1 Surname: Full Names: ID: Date of Birth: Relationship: Child 2 Surname: Full Names: ID: Date of Birth: Relationship: Child 3 Surname: Full Names: ID: Date of Birth: Relationship: Child 4 Surname: Full Names: ID: Date of Birth: Relationship: Child 5 Surname: Full Names: ID: Date of Birth: Relationship: E-EXTENDED FAMILY extended family 1 Surname: Full Names: ID: Date of Birth: Relationship: extended family 2 Surname: Full Names: ID: Date of Birth: Relationship: . EMPIRE TM INVESTMENTS (Pty) Ltd. Authority and Mandate for payments Instruction: Electronic and Written Mandates Account holder: Address: : Bank: Branch and Code: Account Number: Type of Account: Current (Cheque)SavingsTransmission Amount: Date: Contact Number: This signed Authority and Mandate refers to our contract dated (“the Agreement”). I / We hereby authorise you to issue and deliver payment instructions to your Banker for collection against my / our abovementioned account at my / our above-mentioned Bank (or any other bank or branch to which I / we may transfer my / our account) on condition that the sum of such payment instructions will never exceed my / our obligations as agreed to in the Agreement and commencing on and continuing until this Authority and Mandate is terminated by me / us by giving you notice in writing of not less than 20 ordinary working days, and sent by prepaid registered post or delivered to your address as indicated above. The individual payment instructions so authorised to be issued must be issued and delivered as follows: monthly. In the event that the payment day falls on a Sunday, or recognised South African public holiday, the payment day will automatically be the preceding ordinary business day. Payment Instructions due in December may be debited against my account on I / We understand that the withdrawals hereby authorized will be processed through a computerized system provided by the South African Banks and I also understand that details of each withdrawal will be printed on my bank statement. Each transaction will contain a number, which must be included in the said payment instruction and if provided to you should enable you to identify the Agreement. A payment reference is added to this form before the issuing of any payment instruction. Mandate I / We acknowledge that all payment instructions issued by you shall be treated by my / our above-mentioned Bank as if the instructions have been issued by me/us personally. Cancellation I / We agree that although this Authority and Mandate may be cancelled by me / us, such cancellation will not cancel the Agreement. I / We 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. Assignment I / We 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.