B0111

2017

NB05032019

PruCustomer Line: 1800 333 0333 (Local)+65 6333 0333 (Overseas)

CREDIT CARD AUTHORISATION FORM (New Business proposal only)Important Notes

1. Not applicable to Corporate / Debit Cards / American Express / Diners Club / JCB / UnionPay / Non-Singapore issued Credit Cards.2. Credit Card payments are accepted only for policies with existing premium payment methods by cash, cheque or GIRO and are expressed in

Singapore Dollars.3. Credit Card may not be used for payment of premiums for:

(i) Single premium policies, recurring single premium policies, US Dollar policies and policies purchased under the CPF Investment Scheme and Supplementary Retirement Scheme.

(ii) PruShield premiums funded by Medisave and where the premium amounts are within the Medisave withdrawal limits.

4. Payments by non-Singapore issued Credit Cards:

(i) are not encouraged for First Premium payment(s). However, if Proposer or Cardholder has instructed Prudential to debit from his/her non-

Singapore issued Credit Card card, the Proposer or Cardholder will need to bear all charges (administration fees, foreign exchange charges, etc)

imposed by the issuance bank.

(ii) will not be accepted for renewal/one-time premium payments.

5. Upon the approval of this application, the premium amount will be charged to the Cardholder’s Credit Card and his/her Credit Card statement will show the amount deducted. No Premium Notices and Official receipts will be issued. The relevant entries in the Cardholder’s Credit Card statement will be recognised as evidence of payments.

6. If the policy transactions are not taken up subsequently, premiums paid through this application will be reversed back to the Credit Card account.7. All authorisations referred in this application shall remain in force until receipt of Proposer, Policyowner or Cardholder’s revocation to Prudential.8. Each of the specific authorisations set out in this application shall be in addition to any other consent and/or disclosure that the Proposer, Policyowner or

Cardholder may have provided to Prudential and the Bank.9. If the Cardholder is not the Policyowner, he/she has no right under the Contract (Rights of Third Parties) Act, Cap 53B, to enforce any of the terms and

conditions of that policy.

By completing this Application Form, I am instructing and authorising: (i) Prudential and the Bank to automatically debit my Credit Card account to pay for my own and/or my Family Member's policy/policies. "Family Members"

shall mean spouse, children, parents, parents-in-law, brothers and sisters; (ii) Prudential and the Bank to charge an amount different from that stated in this application form, arising from a change of the amount that is required to be

paid as premium (including but not limited to backdated premiums and an increase in premium due to a change in sum assured or if special terms and conditions apply to the proposal for life assurance);

(iii) Prudential and the Bank to change the expiry date of the Credit Card, so long as there is no change in the name of the Cardholder and the Credit Card number;

(iv) the Bank to notify Prudential of any change in my Credit Card account details. In the event that any new Credit Card account is issued to me in addition to/as replacement of/in lieu of the Credit Card account as indicated in this Application Form, these terms and conditions shall be deemed to apply to each such new Credit Card account and I hereby irrevocably authorise the Bank and Prudential to debit each new Credit Card account for the payment of all permitted regular premiums in relation to the policies indicated herein;

(v) and consenting to Prudential to use, disclose any information collected and/or held (whether contained in this form or otherwise obtained) to its associated individuals/organisations and/or independent third parties, within or outside Singapore, with regard to any matters pertaining to this form/policies; and

(vi) should payment not be successfully effected pursuant to this authorisation for any reason, Prudential shall under no circumstances be held responsible or liable in any manner whatsoever including any subsequent expiry of the policies due to late or non-payment of premiums.

I have read the terms and conditions set out in this Application Form and marked "Important Notes", and I agree to be bound by the said terms and conditions.

Proposal / Policy No. Name of Proposer / Policyowner

Name of Cardholder Credit Card No.

- - -

Expiry Date (MM/YY)

/

Please select () one of the following authorisations as appropriate

Proposer or Policyowner’s Signature (as in Prudential’s record)

/ Date (dd-mm-yyyy) Cardholder’s Signature / Date (dd-mm-yyyy) (if different from Proposer / Policyowner)

Prudential Assurance Company Singapore (Pte) Limited (Reg. No.: 199002477Z) Postal Address: Robinson Road P.O. Box 492, Singapore 900942Website: www.prudential.com.sg Part of Prudential Corporation plc

NB05032019

Please complete this form and return to Prudential Assurance Company Singapore (Pte) Limited

First premium only - All credit cards issued in Singapore - For UOB channel, strictly credit card issued by SCB, UOB, Citibank, DBS/POSB, Maybank or OCBC Bank

First and Renewal Premium - Strictly credit card issued in Singapore, from SCB, UOB, Citibank, DBS/POSB, Maybank or OCBC Bank only.

Amount to be billed

$ L5CCARD