G H 2 V 2 5 9 4 1 9 0

MANDATE FORM Policy Number

-

PAYMENT DETAILS
Commencement Date 2 0 2 4 0 7 0 1 Enterprise Life will change this date according to circumstances

Please tick one of the options below

1 Stop Order * Please fill in Stop Order Details 2 Debit Order * Please fill in Debit Order Information

PAYER DETAILS
First Name(s)

J A C Q U E L I N E A N I MA H
Surname
O WU S U
ID Number Date of Birth (YYYYMMDD) Cell (Pre-fix for other countries)

1 9 9 6 0 9 2 5 + 2 3 3 5 0 2 7 0 1 7 4 3

DEBIT ORDER INFORMATION

To avoid high bank penalty charges, as well as the possibility of the policy lapsing - please ensure you have enough money in your account each month
on the day you have chosen for your debit order.

Type of Bank Account Premium Account Holder Name

S A V I N G S 2 0 0 . 0 0 J A C Q U E L I N E A N I MA H OWU S U
Account No. Name of Bank

1 1 3 1 0 7 0 1 6 5 2 1 9 9 0 1 A G R I C U L T U R A L D E V E L O P M E N T
Branch Branch Code

M A D I N A B RA N C H 0 8 0 1 1 3

(0,5,10,15,20,25,30)
INFLATION PROTECTOR: 0%
I the undersigned, hereby authorise Enterprise Life Assurance Company to deduct the premium from my bank account or from any other account to
Enterprise Life Assurance Company
I agree that my bankers withhold an amount equal to my premium, including any premium updates that may be due at all times to ensure I am
adequately covered under this policy

Payer's signature

Signed Date (YYYYMMDD)

2 0 2 4 0 6 2 0

STOP ORDER DETAILS (PREMIUM MANDATE)

Chief Paymaster / Employer

Pay Point / Compiling / Pay Office Initial Deduction end of Employee Number

Initial Monthly Premium

GHc INFLATION PROTECTOR: % (0,5,10,15,20,25,30)

I the undersigned hereby authorise the accountant to deduct the premium from my salary and remit the payment to Enterprise Life Assurance Company
Limited with effect from
OFFICER OTHER RANK SENIOR CIVILIAN JUNIOR CIVILIAN
STAFF CATEGORY:

Premium Payer

Signed Date (YYYYMMDD)

Employee's Accountant

Signed Date (YYYYMMDD)