Direct Debit Request and Service Agreement

Your Surname or company name

Your Given names or ABN/ARBN

Request and authorise Masefield Holdings Pty Ltd ATF The Graham Knight Unit Trust trading as GSK Insurance Brokers (GSK), User ID 378386, ABN 70 970 795 411 to arrange a debit to your nominated account to pay for Insurance.

This debit or charge will be arranged by GSK’s financial institution and made through the Bulk Electronic Clearing System Framework (BECS) from your nominated account and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.

Any amount GSK has deemed payable by you.

OR

The amount specified in the invoice we have sent you, for payment on a due date

Name/s on account:

Financial institution name

BSB number

Account number

Address

Email

Phone

By signing and/or providing us with a valid instruction in respect to your Direct Debit Request you confirm that:

• you are authorised to operate the nominated account; and
• you have understood and agreed to the terms and conditions set out in this Request and in your Direct Debit Request Service Agreement.

Signed in accordance with the account authority on your account:

Signature

Date

Contact details: As above

Signed in accordance with the account authority on your account:

Signature

Name

Address

Email

Phone

Date

You must be authorised to sign on behalf of the company AND you must have authority to operate the Company’s bank account.

Signature of duly authorised officer

Position held

Name

Address

Email(Notices will be sent to this email address)

Phone

Date

Second company signatory (if required)

Signature of duly authorised officer

Position held

Name

Address

Email(Notices will be sent to this email address)

Phone

Date

Direct Debit Request and Service Agreement

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