Household Policy

I hereby declare that the policy, in respect of which these deductions are being made, is being effected by me and I recognise that, beyond making and remitting deductions as specified above, my employer accepts no further responsibility of any kind in this matter. I hereby authorise my employer to deduct from my salary, the contributions plus future increases in respect of the policy as set out above and to have these deductions remitted to Halligan Insurances. I recognise that these deductions will be made solely for my convenience and may be discontinued by you at any time. I also recognise that the ultimate responsibility for ensuring the deductions have in fact been made rests with me.

By signing this mandate form, you authorise (a) Halligan Insurances to send instructions to your bank to debit your account and (b) your bank to debit your account in accordance with the instruction from Halligan Insurances. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.