Liberty Group Limited (registration no.

1957/002788/06) - an Insurer and an Authorised Financial Services Provider

(no. 2409)
Liberty Centre, 1 Ameshoff Street, Braamfontein, Johannesburg, 2001
PO Box 10499, Johannesburg, 2000
Contact Centre number: 0860 456 789 / +27 (0)11 558 4871
DEBIT ORDER PAYMENT FORM
• This form is used to:
o Authorise Liberty to take money from a bank account for a policy premium or loan repayment.
o Add or amend regular contributions for the Evolve Investment Range.
• If the bank account is in the name of a company, close corporation, partnership or trust, an authorised officer must stamp or seal and sign the
form. The officer’s title must also be included on the form.
• Please provide proof of account in the account holder's name i.e. a copy of a cancelled cheque OR copy of a current bank statement on a bank
letterhead OR a copy of printout from the bank with a bank stamp or a letter from the bank on a letterhead.
• No other documents are required with this form.
• We are required to share, collect and process your Personal Information (PI). Your PI is collected and processed by our staff, representatives or
sub-contractors and we make every effort to protect and secure your PI. You are entitled at any time to request access to the information
Liberty has collected, processed and shared.

Send the completed form to Liberty by: • Email: info@liberty.co.za • Post: PO Box 10499, Johannesburg, 2000

Policy details (All details in this section must be completed)

Policy number/s 6 8 0 0 1 5 2 2

Policyholder details
Title Miss Full first names Dieketseng Gladys Gender M ✔ F
Surname/Company/Trust name Khoase Maiden name
ID/Passport/Company registration number 8607270284080 Company registration date
If passport: Country of issue Date of issue Date of expiry
If company: Country of incorporation Trading name
Date of birth 27/07/1986 Place of birth Country of birth
Country of residence South African resident? ✔ Yes No
Marital status: ✔ Single Engaged Married Date of marriage
Widowed Separated Divorced Date of divorce
Email address 1 dk.khoase@gmail.com
Email address 2
Contact numbers: Home Work Cell 079 678 4223
Residential address 17767 Ext 10 Orange Farm Postal code 1841
Postal address 17767 Ext 10 Orange Farm Postal code 1841
Business address Postal code
Nominated occupation Sales Manager Industry of occupation Insurance
SA Income Tax number 2155477157

Account holder details (Complete if the account holder is different to the policyholder)
Title Full first names Gender M F
Surname/Company name
ID/Passport/Company Date of birth/ Company
registration number registration date
If passport: Country of issue Date of issue Date of expiry
If company: Country of incorporation
Country of residence Relationship to policyholder
Relationship to life assured
Marital status: Single Engaged Married Date of marriage
Widowed Separated Divorced Date of divorce

Please note that in the event of any modification or variation of this standard form Liberty will regard this form as being
invalid and of no force and effect. Do not sign blank or incomplete forms.
PA722 03/2020 – Page 1 of 2
Debit order details
This debit order is for:
The payment of premiums: Liberty will debit the bank account at the agreed premium frequency, for premiums owing on the policy.
The repayment of a loan: Liberty will debit R from the bank account each month, in addition
to the policy premium (if applicable).
Debit date 27/06/2021
Regular contributions (Only for the Evolve Investment Range, excluding Preservers)
Total regular contribution R (Minimum R500 p.m. for Investment or R350 p.m. for R.A.)
Which date in the month should we debit your bank account?
How frequently do you want to invest: Every month Every 3 months Every 6 months Every 12 months
How much do you want your regular contribution to increase by each year? % (0% - 20%)
If all the required documents are received less than five days before this date, Liberty may only start collecting your regular contribution in the
next month.
Where must your money be invested?
Portfolio name Regular contribution

1. %
2. %
3. %
4. %
5. %
6. %
7. %
Total investment 100%

Bank account details

• I/We agree that Liberty may debit my bank account according to Liberty’s debit order system for any amount/s due under this/these policies
and I/we agree to inform Liberty in writing of any changes to the account details.
• Transmission accounts and credit cards cannot be used for debit orders.
• It is important to give the correct, full name and spelling of the account.

For Regular Contributions (Evolve Investment range only)

• I understand that my regular contribution will be reduced by any advice fee I have agreed to pay my financial adviser. The balance will be
invested into my choice of portfolios.
• I understand that the portfolios I have selected for my regular contributions will also be used for any future additional lump sum contributions that
I may invest.

Bank name Discovery Bank Account number 12374656118

Branch name Discovery Universal Branch Branch code 679000

Account type: ✔ Current Savings Transmission

Signed at Weldevreden Park on 03/06/2021

Signature of account holder Signature of Policyholder

Name Dieketseng Gladys Khoase Name Dieketseng Gladys Khoase
Capacity Owner Capacity Owner

Track your financial future in your own time with MyLiberty

Visit www.liberty.co.za and logon to MyLiberty for round-the-clock, convenient access to your information.
MyLiberty enables you to:
 View your policy information  View your premium status
 Update your personal details  View and download your correspondence from Liberty
 Download your tax certificates  Find your Financial Adviser's contact details
 View your investment values

You will also find our range of Fund Fact Sheets, Performance Summary documents, financial planning tools and calculators online.

PA722 03/2020 – Page 2 of 2