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1. SECTION A – CONTACT DETAILS
SECTION B – BANKING DETAILS
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Head office use only
ID number
Policyholder
Tel no
Cell no
Name of employer
Fax no
Email
Payment due date: variable to coincide with my salary receipt date
NB: Copy of bank statement must be attached.
AVBOB Mutual Assurance Society is an authorised financial services provider
DEBIT ORDER AUTHORISATION FOR PREMIUMS AND DEBT REPAYMENTS
Postal address
Residential address
Postal code
Postal code
POLICY NUMBER
Account holder
Account number
ID number
Branch code
City/town
Name of bank
Cell no
Branch name
Type of account
Savings Transmission Cheque
AVBOB
AVBOB MUTUAL ASSURANCE SOCIETY
368 Madiba Street, Pretoria, 0002
PO Box 1661, Pretoria, 0001
Tel: 0861 28 26 21
Email: info@avbob.co.za

2. Amount to be debited monthly
SECTION C – LOAN REPAYMENT AMOUNT
Amount to be debited monthly
SECTION D – PREMIUM AMOUNT
Amount to be debited monthly
SECTION F – PREMIUM DEBT AMOUNT
Amount to be debited monthly
SECTION E –
AUTOMATIC NON-FORFEITURE
REPAYMENT AMOUNT
Sections C, E and F: Send completed document to info@avbob.co.za or fax to 012 303 1383.
I hereby authorise AVBOB Mutual Assurance Society to debit my account with the above-mentioned bank for the
amounts payable as specified herein. I acknowledge that the payment due date will vary from month to month to coincide
with my salary remuneration dates as determined by my employer and request AVBOB Mutual Assurance Society to
debit my account on these dates or as close as possible to these dates.
Section D: Send completed document to debitorders@avbob.co.za or fax to 0866 789 469.
SECTION G – AUTHORISATION
SIGNATURE OF ACCOUNT/CARD HOLDER DATE
YYYYMMDD
R
R
R
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