AUTHORITY AND MANDATE FOR PAYMENT INSTRUCTIONS BY CRISIS QUANT DEBIT SERVICE ON BEHALF OF LIFE MED
1. I / We hereby authorize Crisis Quant Debit Services (Pty) Ltd, 624 Makoustreet, Monumentpark, to issue and deliver payment instructions to your banker for collection against my / our bank account provided below at my / our bank supplied below.
2. The individual payment instructions so authorised to be issued must be issued and delivered monthly/bi-monthly/three-monthly/six-monthly/annually/weekly/bi-weekly* (interval) on the date when the obligation in terms of the Agreement is due and the amount of each individual payment instruction may not differ as agreed to in terms of the Agreement. *(Delete what is not applicable)
3. The payment instructions so authorised to be issued must carry unique identifier, which must be included in the said payment instructions and if provided to you should enable you to identify the Agreement on your bank statement. The said identifier should be added to this form in section E before the issuing of any payment instruction and communicated to me directly after having been completed by you.
4. I/we agree that the first payment instruction will be issued and delivered on _________________ (date) and thereafter regularly according to the agreement, *except for payment instructions due in December which maybe debited against my account on _________________*If applicable. I / we agree that payment instruction will be issued and submitted on the day of the month indicated (mark applicable day with X).
1ST7TH15TH26THIf however: (Please indicate)
____ The date of the payment instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the following business day: or
____ The date of the instruction falls on a non-processing day (weekend or public holiday) I agree that the payment instruction may be debited against my account on the business day prior to the non-processing day.
____ To allow for tracking of dates to match with flow of Credit at no additional cost to myself.
____ I authorise the originator to make use of tracking facility as provided for in the EDO system at no additional cost to myself.
5. Subsequent payment instructions will continue to be delivered in terms of this authority until the obligations in terms of the Agreement have been paid or until this authority is cancelled by me/us by giving you notice in writing of not less than the interval (as indicated in the previous clause) and sent by prepaid registered post or delivered to your address indicated above.
I / we acknowledge that all payment instructions issued by Crisis Quant Debit Services shall be treated by my/our abovementioned bank as if the instructions had been issued by me/us personally.
I / we agree that although this authority and mandate may be cancelled by me/us, such cancellation will not cancel the Agreement. I/We also understand that I/we cannot reclaim amounts, which have been withdrawn from my/our account (paid) in terms of this authority and mandate if such amounts were legally owing to you.
I / We acknowledge that this authority may be ceded or assigned to a third party if the agreement is also ceded or assigned to that third party.
Terms and Conditions:
1. VitalRide Members only covers your immediate nuclear family (Father, Mother and children up to 21 years of age).
2. VitalRide Membership undertakes to arrange ambulance support to members when such need arises.
3. Only ambulances activated from VitalRide managed control centre will be covered by this product. If you or anyone else has phoned another ambulance directly VitalRide Membership will not cover the cost of that service rendered to you.
4. It is the responsibility of the client to provide adequate information about the emergency and location to ensure quick response by the network of ambulances.
5. Every emergency call must go through the Life Med emergency number 0861 086 911. Life Med will dispatch other service if needed.
6. VitalRide is not an insurance program. It will not compensate or reimburse other ambulance companies providing Emergency Medical Services.
7. If your membership was not renewed or a monthly payment is missed and you requested service you will be responsible for the total cost.
8. VitalRide Membership only covers you in the boundaries of South Africa.
9. Non-emergency calls or patients refusing to go to hospital will be billed by the attending ambulance service provider for services rendered. This is not covered by the product.
10. Only emergency calls will be covered example gunshots, drowning’s, no breathing, heart attacks and stroke. We don’t cover headache,stomach aches, sprains or transfers to Doctors appointments or to X-rays.
11. VitalRide membership shall not be held liable for any loss or damage whatsoever arising out of delay in rendering service or for any other reason whatsoever including, but not limited to, circumstances beyond the control of Life Med. Life Med will not be held liable for any loss, injury, death, damages, consequent loss or special damages of any kind or nature for any reason whatsoever arising out of this agreement, whether as a result of negligent act or omission by Life Med, its employees, agents and/or assigns.
12. VitalRide membership terms and conditions may change from time to time without prior notification.
13. A standard fee of R30-00 will apply for lost, stolen or damaged VitalRide Membership cards that must be replaced.
14. In the event where areas are not accessible by ambulances other modes of transport will be arranged, but is not covered by this product the member will be liable for the costs.
15. Termination can be effective immediately with no refunds of annual/monthly fees to the member if the member misuses the services for non- emergency calls or not medically related calls or emergencies.
16. It is the responsibility of the customer to ensure that all details given to VitalRide Membership are correct and up to date. Written notice must be given for any Changes of membership. Email changes to email@example.com
17. Cover not available where the injury, accident or illness is self-inflicted.
18. Maximum cover per single emergency claim R4000-00.
19. If an ambulance was dispatched for a non-medical emergency as specified above, the member may be held liable for the cost of service.
20. If you are on a medical aid, Life Med can claim from your medical aid. In the event that your fund is exhausted or there is a short payment, the cost will be covered by the VitalRide membership and no cost to the client/patient.
I HEREBY UNDERSTAND THE TERMS AND CONDITIONS THAT IS SET OUT ABOVE.