Insurance instruction acknowledgment

How will this form be signed*

Now, in person or via screen sharingPrinted and signed in person or via email

Please note that Docusign can only be used by one person at a time. Please print and sign this form for two people or complete a seperate form for each person.

How many people will complete this form?*

12

To: Enva Australia Pty Ltd - Australian Financial Services Licensee 424494

I *

First NameLast Name

Email of first party*

example@example.com

or We (if signed by two people)*

First NameLast Name

Email of second party*

example@example.com

Of (Address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

have elected to provide you with specific instructions to buy, modify or cancel an insurance policy, the details of my/our instructions have been provided to you.

I understand that no data collection form or specific personal information was offered by me regarding my affairs and that I have requested that these instructions be executed without any personal advice being given. By providing general information to us about these products, we acknowledge that we have received general financial advice only.

I understand that I have the right to request personal advice regarding my instructions and I decline to receive such advice at this stage. I note that should we wish to receive personal advice regarding these products, Enva is willing and able to make an appointment and provide personal advice. We have declined this offer at this stage.

I acknowledge that I have received a “Financial Services Guide” that outlines important information that includes contact information for Enva, my rights and Enva Australia’s products and services along with Enva’s obligations.

I understand that by not seeking financial planning personal advice regarding this product, I risk making a decision which may not be suitable to my financial needs.

I understand that the Enva Australia or it’s nominated Authorised Representative will receive the following payment from the insurer as a result of my instructions and that this payment does not create an obligation for Enva Australia or it’s representatives to provide initial or ongoing financial advice. The payment received will be to assist in completing my application to the insurer, carrying out further instructions with respect to my policy and assisting with a claim on my policy should I need this in the future so long as my policy is still administered by an authorized representative of Enva Australia.

have elected to provide you with specific instructions to buy, modify or cancel an insurance policy, the details of my/our instructions have been provided to you.

We understand that no data collection form or specific personal information was offered by us regarding our affairs and that we have requested that these instructions be executed without any personal advice being given. By providing general information to us about these products, we acknowledge that we have received general financial advice only.

We understand that I have the right to request personal advice regarding my instructions and we decline to receive such advice at this stage. We note that should we wish to receive personal advice regarding these products, Enva is willing and able to make an appointment and provide personal advice. We have declined this offer at this stage.

We acknowledge that I have received a “Financial Services Guide” that outlines important information that includes contact information for Enva, our rights and Enva Australia’s products and services along with Enva’s obligations.

We understand that by not seeking financial planning personal advice regarding this product, we risk making a decision which may not be suitable to my financial needs.

We understand that the Enva Australia or it’s nominated Authorised Representative will receive the following payment from the insurer as a result of my instructions and that this payment does not create an obligation for Enva Australia or it’s representatives to provide initial or ongoing financial advice. The payment received will be to assist in completing my application to the insurer, carrying out further instructions with respect to my policy and assisting with a claim on my policy should I need this in the future so long as our policy is still administered by an authorized representative of Enva Australia.

Products and payments*

	Product Name	Initial Payment ($/%)	Ongoing Payment ($/%)
Product 1
Product 2
Product 3
Product 4

Execution by client:

I agree to abide and be bound by the terms and conditions of this letter agreement with Enva Australia Pty Ltd.

Execution by client:

We agree to abide and be bound by the terms and conditions of this letter agreement with Enva Australia Pty Ltd.

Signature*

Signature of party 2*

Enva Australia (ABN 21 098 806 501) Australian Financial Services Licence No. 424494.

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