Mr Narcis Mazilu
46 College Avenue
Our Reference MANC48PC01
Between Right Choice Insurance Brokers Limited (RCIB) and Close Brothers Premium Finance
Following receipt of your deposit, it is agreed that the remaining insurance premium of £1,573.49 can be paid in monthly
instalments as per the schedule below and it is agreed that if the policy is cancelled due to payment default that the certificate
of insurance must be returned on demand.
Day of the month for payments to be collected:- 16
Monthly Instalment amount: - £ 188.82
Number of payments:- 10
*Payments will usually begin being collected within the first month on the above date and on the same day every month
thereafter (or the last working day before, if this falls on a weekend or bank holiday)
Please note that if you have requested a different date then this will NOT be shown correctly on the letter you receive from
the Close Brothers Premium Finance.
It is understood that should any payment be unpaid for whatever reason, Right Choice Insurance Brokers Limited have the
right to recover payment from any card details previously provided to recover such monies owing, or to cancel this policy
following issue of a seven day Notice of Cancellation, however in the event of cancellation any shortfall in the return
premium will still become immediately due.
It is also agreed that the full premium is payable on demand, in the event of a claim occurring under this policy and that no
refund of premium will be due if a claim has been made or still outstanding and that we may at our discretion deduct all
monies owed from your claims settlement.
It is also agreed that in the event of a default that you authorise us to debit any monies owed from any credit or debit card
Please note that a default charge of £20 will be levied for any dishonoured payments.
It is agreed and understood that the finance is provided by “Close Brothers Premium Finance” , the premium will be paid
directly by them to RCIB and if I default on payment to the finance company, the finance providers have the right to reclaim
the full outstanding balance from RCIB and in these circumstances I agree to pay RCIB upon request the sum reclaimed by
the finance company and if I do not pay this sum on demand, RCIB then have the right to cancel the policy and take further
action to recover the amount due.
Print Name: Mazilu Narcis Signed: Mazilu Narcis
Persons aged under the age of eighteen (18) must have this form signed by a parent / guardian who will be responsible and
liable to make these payments.
Parent / Guardian ……………………………. Print Name ……………………………………