BUDGET PLAN Monthly Instalment Application

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Monthly Instalment Application

     Budget Plan
     Gives you the credit you deserve

     Even the best managed personal or business finances occasionally have to
     cope with inconvenient single lump sum payments. AXA Insurance’s Budget
     Plan with simple monthly payments helps avoid this by spreading the cost
     of your insurance over the whole year.

     What's more, Budget Plan is highly flexible, and offers many time
     saving benefits.

     Peace of Mind                                 Easier Renewal Procedures
     Payment by Direct Debit means that            When you decide to renew your policy
     there's no risk of forgetting to pay, or of   with AXA Insurance, no new Budget
     payments going astray in the post. This       Plan agreement is required. The original
     way, you know that your cover is              agreement, and your Direct Debit
     always in force. And, with Direct Debit,      payment arrangements, will continue
     you are guaranteed against any error          until you cancel them.
     on our part as to the date or amount of
     the payment.                                  So at home or at work, use Budget
                                                   Plan to help you manage your
     Easier Premium Adjustments                    finances and to give you the
                                                   insurance cover you prefer.
     Over a year, amendments may be
     necessary to your annual insurance            Insurance Premium Tax (I.P.T.) – This
     premium (for example, following a             applies to all UK policies.
     change of motor vehicle or business
                                                   How to Join
     premises). With Budget Plan your
     monthly payments are automatically            Simply fill in the Budget Plan
     adjusted. If the amounts to be paid           Application Form and Direct Debit
     change, you will be told of this in           Instruction opposite.
     advance by at least 10 days as agreed
     with APACS.                                   If you need further help or guidance, or
                                                   require a copy of your Application Forms
     Choice of Payment Days                        contact us at:
     It is often more convenient to pay            Please return both the Application
     instalments at a particular stage of the      Form and Direct Debit to your
     month. Depending on the renewal               Insurance Adviser or nearest AXA
     date you choose, payments may be              Insurance Branch within 7 days of
     made on the 7th, 14th, 21st or 28th of        your inception or renewal date.
     each month.
     Multiple Policies – One Budget Plan
     If you have more than one policy with
     AXA Insurance, you need only arrange
     one Budget Plan (provided only that you
     choose the same renewal date for each
     policy). So if you need another policy,
     there's no need to fill in another Budget
     Plan application.
Budget Plan Application Form
 Please Read Carefully: I wish to pay my Insurance Premiums by instalments, in respect of the policies listed below,
 and others I may add. I confirm that –
 • I am 18 years old or over.
 • The instalments will be paid monthly by Direct Debit.
 • I have read, and accept, the Terms and Conditions of the AXA Insurance Budget Plan, printed overleaf which you
   will confirm in writing before the first Direct Debit is collected. In particular, I agree that funds will be available in
   my nominated bank account to meet each monthly instalment on the agreed date. I understand that, if any
   instalment is not paid, the policy(ies) will be cancelled, and benefits cease, with immediate effect, or where statute
   requires the giving of prior notice the day following expiry of such notice. In such an event, I agree to surrender
   immediately to the Company any relevant Road Traffic Act or Employer's Liability Certificate.
 • I also understand that interest at the prevailing rate will be charged on the total premium less my deposit.
   At the time of printing the rate is 13.44% APR.

Signature(s)                                                                         Date


Policy holders name and address
Title Mr/Mrs/Miss/Ms                       Forename(s)




Policies to be included
 Please note that where applicable, all premiums should be shown inclusive of the standard Insurance Premium
 Tax rate applicable at the present time.

       Class           Type          Policy Number             Renewal date                Premium or Estimated

      Protect add?              L.C.P.           Total Premium (min £60)               £

 Please also complete the Direct Debit Instructions opposite

 Intermediary Name                                               Intermediary No.

                                                                 Inst. Ref
Instruction to your Bank or Building
Society to pay by Direct Debit
Please fill in the whole form using a ballpoint pen and
send it to your Insurance Adviser or nearest AXA
Insurance branch.
                                                                      Originator’s Identification Number

                                                                       7 0 6 0 4 1

Name(s) of Account Holder(s)                                          Reference Number (for branch use only)

Bank/Building Society account number

Branch Sort Code

Name and full postal address of your Bank or Building Society

 To: The Manager                                                                       Bank/Building Society


Instruction to your Bank or Building Society.
Please pay AXA Insurance UK plc Direct Debits from the account detailed in this Instruction subject to the
safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with AXA
Insurance UK plc and, if so, details will be passed electronically to my Bank/Building Society.

Signature(s)                                                       Date


Banks and Building Societies may not accept Direct Debit Instructions for some types of account
This guarantee should be detached and retained by the Payer.

The Direct Debit Guarantee

•   This Guarantee is offered by all Banks and Building Societies that take part in the Direct Debit Scheme.
    The efficiency and security of the Scheme is monitored and protected by your own Bank or Building Society.

•   If the amounts to be paid or the payment dates change AXA Insurance will notify you 10 working days in
    advance of your account being debited or as otherwise agreed.

•   If an error is made by AXA Insurance or your Bank or Building Society, you are guaranteed
    a full and immediate refund from your branch of the amount paid.

•   You can cancel a Direct Debit at any time by writing to your Bank or Building Society.
    Please also send a copy of your letter to us.
                                       YOUR RIGHTS UNDER THIS CREDIT AGREEMENT Budget Plan

Your Rights Under this Credit Agreement
IMPORTANT – You should read this carefully.
The Consumer Credit Act 1974 covers this agreement and lays down certain requirements
for your protection which must be satisfied when the agreement is made. If they are not,
the creditor cannot enforce the agreement against you without a court order.
The Act also gives you a number of rights. You have a right to settle this agreement at any
time by giving notice in writing and paying off all amounts payable under this agreement
without further charge for credit.
If you have any difficulty in paying any sum under the agreement or taking any other action
required, you can apply to the court which may make an order allowing you or a guarantor
more time to pay.
If you would like to know more about the protection and remedies provided under the Act,
you should contact either your local Trading Standards Department or your nearest
Citizens' Advice Bureau.
Banks may decline to accept instructions to charge Direct Debits to certain types of
account other than current accounts.

Terms and Conditions of AXA Insurance
Budget Plan
1 This credit agreement may only be taken       7 AXA Insurance reserves the right to
  out by persons who are at least 18 years        deduct any outstanding balance of unpaid
  of age. The total premiums covered by the       premium payments from any claim
  agreement must be at least £60.                 settlement that may be due.
2 The commencement date of this                 8 If for any reason an additional or return
  agreement is the date of the signature.         premium is added to this scheme (for
                                                  example following a change of motor
3 This agreement will continue until
                                                  vehicle), the current interest rate will also
  cancelled in accordance with the
                                                  be applied to the extra premium, on a pro-
  provisions of term 9.
                                                  rata basis.
4 All payments under this credit agreement
                                                9 This agreement can be cancelled if:
  can ONLY be by Direct Debit from your
  Bank account for the amounts specified in         (a) either party gives the other 7 days'
  AXA Insurance’s statement letter unless               notice of cancellation in writing
  otherwise stated.You must notify AXA
  Insurance of any changes in your banking          (b) you fail to make due payment, and
  details to ensure payment on time.                    do not make good the amount within
                                                        7 days of our request to do so.
5 You undertake to maintain sufficient funds
  in the account to meet each payment.          10 Upon cancellation of this credit
  Failure to make good any missing                 agreement the balance of the monies
  payment within the period specified will         due will become immediately payable.
  result in cancellation of your policy(ies)    11 If you are in default of this agreement
  with effect from the default date.               and the agreement is cancelled by us
6 AXA Insurance reserves the right to vary         you must immediately surrender to AXA
  the interest rate charged, but should this       Insurance any Employer's Liability or
  prove necessary, you will be given at least      Road Traffic Act Certificate of Insurance
  one month's notice.                              or Cover Note.
        AXA is a world leader in wealth management and financial protection. We
        operate in 50 countries and serve more than 50 million customers worldwide. We
        cater to a wide range of needs, providing advice and guidance to our individual
        and corporate customers on a variety of financial products and services. These
        include investments, life assurance, retirement planning, long term care, asset
        management, medical insurance, dental and hospital care services as well as
        motor and home insurance.

        With our expertise and commitment to customer service and
        consistent quality care, you can rely on AXA for lasting security.

                       ASK ABOUT AXA’S EXCELLENT
                       RANGE OF INSURANCE PRODUCTS


                                                                                                                                WAT225N (01/05) (T2450)

                                                    AXA Insurance UK plc
                   Registered in England No 78950. Registered Office: 107 Cheapside, London EC2V 6DU
A member of the AXA Group of Companies. AXA Insurance UK plc is authorised and regulated by the Financial Services Authority.
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