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Get AU IMAN Direct Debit Request & Claims Benefit Form 2019-2024

To arrange for funds to be debited from my/our nominated account via the Bulk Electronic Clearing System at the financial institution shown below according to the schedule specified below. Your personal details Date of Birth Customer Number / Title / Given name/s Surname Residential address in Australia (include suburb, state and postcode) Suburb State Postcode Pay your premium automatically (please choose one option below) Automatic payments from your nominated Australian bank acco.

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