I confirm that I accept this Authority and Mandate and that I’m bound by the payment terms applicable to this policy agreement. I authorise Hollard Life Assurance Company to debit all monthly premiums due on this policy against the above bank account on the 1st day of each month. If a payment is unsuccessful, I authorise Hollard Life Assurance Company to re-present the debit instruction against the same account to meet my obligations under this agreement. If two (2) consecutive debit order collections are unsuccessful, Hollard Life Assurance Company may cancel the policy in accordance with the policy terms and applicable notice requirements.