Download APPLICATION FOR REGULAR PREMIUM PAYMENT BY CREDIT

PruCustomer Line: 1800 -333 0 333
APPLICATION FOR REGULAR PREMIUM PAYMENT BY CREDIT CARD
Important Notes
Not applicable to Corporate / Debit Cards / American Express / Diners Club / JCB / UnionPay / Non-Singapore issued Credit Cards.
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.
Upon the approval of this application, any premium(s) in arrears (up to a maximum of 2 months' arrears), together with the current month's premium will
be charged to the Cardholder’s Credit Card. Future premium(s) amount will be charged on the due date of the premium(s) and the Cardholder’s Credit
Card statement will show the amount deducted. No Premium Notices and Official Receipts will be issued. The relevant entries in Cardholder’s Credit
Card statement will be recognised as evidence of payments.
5.
If premium payments are made monthly and there is any premium which remains unpaid within the period stated in the terms and conditions of policies
indicated herein in which premium payments are allowed, there will be an additional attempt to charge the premium to the Cardholder’s Credit Card on
either the monthly premium due date or 15 days after.
6.
If Prudential is unable to charge the premium to the Credit Card on the premium due date, another attempt shall be made after 15 days.
7.
If an attempt to charge the Credit Card falls on a Saturday, Sunday or a Public Holiday, it will take place on the next working day.
8.
If the policy transactions are not taken up subsequently, premiums paid through this application will be reversed back to the Credit Card account.
9.
All authorisations referred in this application shall remain in force until receipt of the Policyowner or Cardholder’s revocation to Prudential.
10. Each of the specific authorisations set out in this application shall be in addition to any other consent and/or disclosure that the Policyowner or
Cardholder may have provided to Prudential and the Bank.
11. 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.
1.
2.
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 any additional premium arising from a change of the amount that is required to be paid as premium (including but not
limited to an increase or inclusion of benefits or from a reinstatement with or without special terms and conditions);
(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.
Section A
Please complete this form and return to Prudential Assurance Company Singapore (Pte) Limited
Name of Cardholder
Contact No. (Mobile/Tel)
(Country Code)
Name on Credit Card
Credit Card No.
-
NRIC / Passport No. of Cardholder
Policy No.
-
-
Credit Card Issuing Bank (“Bank”), pls tick  one
SCB
UOB
CITIBANK
DBS/POSB
MAYBANK
OCBC
Expiry Date (MM/YY)
/
Particulars required if Cardholder is not Policyowner
Name of Policyowner
NRIC No.
Cardholder's Signature
Prudential Assurance Company Singapore (Pte) Limited (Reg. No.: 199002477Z)
Postal Address: Robinson Road P.O. Box 492, Singapore 900942
Tel: 6333 0333 Fax: 6734 9555 Website: www.prudential.com.sg
Part of Prudential Corporation plc
S04012017
Total No. of policies
Date (dd-mm-yyyy)
L5CCRN
3.
1. Fold along the dotted lines.
2. Fold and insert your document into this prepaid business reply folder.
Seal along the edges of this prepaid business reply folder with clear tape (do not staple).
4. Drop your sealed prepaid business reply folder into your nearest post box.
Postage will be
paid by
addressee. For
posting in
Singapore only.
BUSINESS REPLY SERVICE
PERMIT NO. 00364
PRUDENTIAL ASSURANCE COMPANY SINGAPORE (PTE) LIMITED
Robinson Road P.O. Box 492
Singapore 900942