We`re here to help you Direct Debit Request Form

Direct Debit
Request Form
We’re here to help you
Contact our friendly team to discuss your payment options,
or any questions you may have about your insurance.
National Free Call 1800 777 156 Facsimile 1800 839 289 Email [email protected]
Your Details
Your MIGA client number (e.g.SM12345)
Your surname or company name
“you”
Your given names or ABN/ARBN
You request and authorise MEDICAL DEFENCE ASSOCIATION OF SOUTH AUSTRALIA LIMITED (APCA ID: 498384) to arrange, through its
own financial institution, a debit to your nominated account any amount MEDICAL DEFENCE ASSOCIATION OF SOUTH AUSTRALIA LIMITED
has deemed payable by you.
This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution
you have nominated below and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.
Payment frequency
(Please tick one)
Annual Direct Debit
Monthly Instalments (Only available if your total annual cost is greater than $1,000)
Only complete this section if paying from a bank account
Bank Details
(if applicable)
Financial institution name
Name(s) on the account
BSB number (must be six digits)
Account number (maximum nine characters)
Signature Name
Date
Address
Second account signatory (if required)
Date
Name of second account signatory & position
Address of second account signatory
By signing and/or providing us with a valid instruction in respect to your Direct Debit Request, you have understood and agreed to the terms and
conditions governing debit arrangements between you and MEDICAL DEFENCE ASSOCIATION OF SOUTH AUSTRALIA LIMITED as set out in this
Request and in your Direct Debit Request Service Agreement.
Only complete this section if paying from a credit card
Credit Card Details
Card type
Visa
MasterCard
American Express
Diners Club
(if applicable)
Credit card number
Expiry date
Name on card
Cardholder’s signature
Date
© MIGA April 2016
Direct Debit Request
Service Agreement
This is your Direct Debit Service Agreement with MEDICAL DEFENCE ASSOCIATION OF SOUTH AUSTRALIA LIMITED, APCA ID: 498384, ABN: 41 007 547 588.
It explains what your obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as your Direct Debit provider.
Please keep a copy of this agreement for future reference. It forms part of the terms and conditions of your Direct Debit Request and should be read in conjunction
with your Direct Debit Request authorisation.
Important Note: Your membership and insurance with MIGA will be cancelled if any instalment payment remains unpaid for one month or more and this
Direct Debit Service Agreement will be cancelled if there are two consecutive defaults of instalment payments.
Definitions
Your obligations
• account means the account held at your financial institution from which we are
authorised to arrange for funds to be debited.
• agreement means this Direct Debit Request Service Agreement between you and us.
• It is your responsibility to ensure that there are sufficient clear funds available in your
account to allow a debit payment to be made in accordance with the Direct Debit
Request.
• banking day means a day other than a Saturday or a Sunday or a public holiday
listed throughout Australia.
• You must tell us at least 7 days prior to the debit day (the 24th day of month) if you
know, for whatever reason, that a direct instalment will fail.
• debit day means the day that payment by you to us is due.
• If there are insufficient clear funds in your account to meet a debit payment you:
a) may be charged a fee and/or interest by your financial institution;
b) may also incur fees or charges imposed or incurred by us; and
c) must arrange for the debit payment to be made by another method or arrange
for sufficient clear funds to be in your account by an agreed time so that we can
process the debit payment.
• debit payment means a particular transaction where a debit is made.
• direct debit request means the Direct Debit Request between us and you.
• us or we means MEDICAL DEFENCE ASSOCIATION OF SOUTH AUSTRALIA LIMITED,
(the Debit User) you have authorised by requesting a Direct Debit Request.
• you means the client who has signed or authorised by other means the Direct Debit
Request.
• your financial institution means the financial institution nominated by you on the
Direct Debit Request at which the account is maintained.
Debiting your account
• By signing a Direct Debit Request or by providing us with a valid instruction, you have
authorised us to arrange for funds to be debited from your account. You should
refer to the Direct Debit Request and this agreement for the terms of the arrangement
between us and you.
•Your account will be debited on the 24th day of the month. If the debit day falls
on a day that is not a banking day, we may direct your financial institution to debit
your account on the following banking day. If you are unsure about which day your
account has or will be debited you should ask your financial institution.
• You should check your account statement to verify that the amounts debited from
your account are correct.
Disputes
•If you believe there has been an error in debiting your account, you should notify
us directly on 1800 777 156 during business hours and confirm that notice in
writing with us as soon as possible so that we can resolve your query more quickly.
Alternatively you can take it up directly with your financial institution.
•If we conclude as a result of our investigations that your account has been
incorrectly debited we will respond to your query by arranging for your financial
institution to adjust your account (including interest and charges) accordingly.
We will also notify you in writing of the amount by which your account has been
adjusted.
•If you elect to pay by monthly instalments, the first instalment payment will be due
on the 24th day of the month prior to the start of your policy period.
•If we conclude as a result of our investigations that your account has not been
incorrectly debited we will respond to your query by providing you with reasons and
any evidence for this in writing.
•If you opt-in to monthly instalment payments after the start of your policy period, all past
due monthly instalment payments will be deducted in the first Direct Debit payment.
Accounts
Amendments by us
You should check:
• We may vary any details of this agreement or a Direct Debit Request at any time by
giving you at least 14 days written notice.
•with your financial institution whether direct debiting is available from your account
as direct debiting is not available through BECS on all accounts offered by financial
institutions.
Amendments by you
You may change*, stop or defer a debit payment, or terminate (cancel) this agreement
at any time by providing us with at least 7 days notification:
• by telephoning us on 1800 777 156 during business hours; or
• by writing to us Level 14, 70 Franklin St, Adelaide, SA 5000; or
• by filling in an electronic ‘Contact Us’ found on our website www.miga.com.au or
• arranging it through your own financial institution, which is required to act promptly
on your instructions.
* Note: in relation to the above reference to ‘change’, your financial institution may
change your debit payment only to the extent of advising MEDICAL DEFENCE
ASSOCIATION OF SOUTH AUSTRALIA LIMITED of your new account details.
•If you do not notify MIGA of a change to your payment details, your insurance
cover may be at risk. Please refer to the Policy Wording and/or Combined Financial
Services Guide and Product Disclosure Statement for full details.
Notice
•your account details which you have provided to us are correct by checking them
against a recent account statement; and with your financial institution before
completing the Direct Debit Request if you have any queries about how to complete
the Direct Debit Request.
Confidentiality
We will keep any information (including your account details) in your Direct Debit
Request confidential. We will make reasonable efforts to keep any such information
that we have about you secure and to ensure that any of our employees or agents who
have access to information about you do not make any unauthorised use, modification,
reproduction or disclosure of that information.
We will only disclose information that we have about you:
a) to the extent specifically required by law; or
b) for the purposes of this agreement (including disclosing information in connection
with any query or claim).
If you have elected to pay by credit card and it has been validated by our financial
institution we will dispose of your details in accordance with the Insurance Contract
Act 1984 and the Privacy Act 1998.
•If you wish to notify us about anything relating to this agreement, you should:
telephone us on 1800 777 156 during business hours or fill in an electronic
‘Contact Us’ found on our website www.miga.com.au. We may send notices either
electronically to your email address or by ordinary post to the address you have
given us. Any notice will be deemed to have been received on the third banking day
after emailing or posting.
© MIGA April 2016