8 Bartlett Lake Office Park CNR Trichardts RD & Leith RD

Eyethu Application Form

Members Details

Dependent Details

Legal Protection Packages

We cover all legal matters
Bail Application - Criminal Matter - Divorce Matter - Maintenance Matter - Domestic Violence - Custody Matter Labour Matter - CCMA - Real Estate - Civil Matter - Unlawful Arrest - Estate

Banking Details & payment Authority

I, the undersigned, hereby confirm that I am duly authorised to enter into and agree to this policy on my behalf. I hereby authorise and mandate Workerslife Insurance Limited (WLIL), an authorised Financial Service Provider to deduct monthly with effect from the Deduction date the premium of of the selected Legal Package from my bank account, until such time as this authorisation in writing is cancelled, or until substituted with a new authorisation. Should the monthly selected debit order date fall on a public holiday or a weekend, I authorise WLIL to debit the abovementioned account on the previous working day. I further authorise WLIL to perform the necessary verification, validation and correction of the debit order details, supplied by me, with my bank or other third parties to ensure that the application form can be processed.

Declaration

1. I warrant that all particulars on the application form are correct, whether in my handwriting or not.
2. I was advised that the Insurer will give 30 days’ notice of cancellation of this policy. I may cancel the policy effective immediately.
We would like to confirm that provided premium has been collected successfully, you are covered for the full cancellation month.
3. I understand that any misrepresentation on or omission from the form may invalidate claims under the policy.
4. Notice of inflationary increases will be sent to the Insured when applicable. Failure to advise to the contrary will serve as acceptance of the new terms.
5. I warrant that there are currently no pending circumstances that could involve legal action against me, or my taking legal action against any third party.

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