Direct Debit Form

AUTHORISATION CODE:

1

2

1

7

2

5

Have you ever been insured by Mariner before?*

Quote Number:

Excess Option

Name of account to be debited:*

Phone Number of account holder:

Account number:*

Bank/Branch:*

Address (PO Box) Town/City*

I/We authorize until further notice in writing to debit my/our account with you all amounts which

Watermark premium funding limited
(hereinafter referred to as the Initiator)

the registered Initiator of the above Authorisation Code may initiate by Direct Debit.

I/We acknowledge and accept that the bank accepts this authority only upon the conditions listed here.

Payer reference

Name of Account*

Authorised Signature(s)*

Please use your mouse (or finger if on a mobile device) to sign above