Credit Card Debit Instruction Form

							                                                     Credit Card Debit Instruction Form
        VISA               MASTERCARD                  Card Issuing Bank

Credit Card Number

Card Expiry Date (MM/YY)                                                                     Tel No:

Name of Cardholder

NRIC (New)

Address
I, the abovementioned Cardholder hereby expressly authorize Uni.Asia Life Assurance Berhad (Please tick where appropriate) :-

[A] INSTRUCTION FOR ONE-OFF TRANSACTION*

      New Business First Premium
      upon approval of the Life Insurance Proposal(s) below or acceptance of a counter offer (as the case may be) of Uni.Asia Life Assurance
      Berhad, to charge the premium via the abovementioned card for the proposals stated below
      APL Repayments/Financial Alteration(Please delete accordingly)
      to charge the payment(s) in respect of the Policy(ies) stated below
      Application for Reinstatement of Policy
      upon approval of the Application towards the Reinstatement for Policy(ies) below or acceptance of a counter offer made by the Uni.Asia
      Life Assurance Berhad, to charge the abovementioned card, the deposit towards reinstatement for the Policy(ies) stated below
      Premium Due on
      to charge the payment(s) in respect of the Policy(ies) stated below

   Proposal/Policy No.                                  Proposer/Assured                                     Proposer/Assured – Cardholder Relationship**




**Limited to Cardholder’s spouse, children, parents and brothers / sisters

[B] INSTRUCTION FOR RECURRING PAYMENTS

      to charge all premiums for Policy(ies) stated above, as and when due to my abovementioned credit card subject to the terms of the policy
      contract.
I, further hereby declare/agree/undertake the following:-
(a) ensure that my credit card account has sufficient funds for the execution of the transaction(s),
(b) the transaction(s) for payment to Uni.Asia Life Assurance Berhad shall be subject to:-
       (i) the acceptance by Uni.Asia Life Assurance Berhad whereupon I shall be informed in writing by Uni.Asia Life Assurance Berhad of the governing procedures and
       (ii) the verification/authorization from the issuing bank of the credit card,
(c) take full responsibility for any transaction(s) arising from the use of the said credit card in payment to Uni.Asia Life Assurance Berhad,
(d) shall notify Uni.Asia Life Assurance Berhad in writing of changes to the credit card number and expiry date and issuance of new/replacement of credit card
(e) that either I or Uni.Asia Life Assurance Berhad may terminate this instruction by giving the other a one (1) month’s written notice, and I shall forward all payments
       due directly to Uni.Asia Life Assurance Berhad,
(f)    shall indemnify Uni.Asia Life Assurance Berhad against all losses, damages, expenses, claims and demands which Uni.Asia Life Assurance Berhad may incur or
       sustain by reason or as a result of processing the transaction(s),
(g) Uni.Asia Life Assurance Berhad shall not be held responsible or liable for any claim, loss, damages, cost, interest and expenses arising from the unsuccessful
       processing of the transactions/debits due to insufficient funds, malfunctions of system, electricity failure and any other factors beyond the control of Uni.Asia Life
       Assurance Berhad, including but not limited to the wrongful transactions/debits of my account due to inaccurate information provided to Uni.Asia Life Assurance
       Berhad whereupon I shall forward premiums due directly to Uni.Asia Life Assurance Berhad.




______________________________                                  ______________________________                                   ______________________________________
Cardholder’s Signature                                          Signature of Proposer / Assured                                  Signature of Witness
Date                                                            Name       :                                                     Name       :
                                                                NRIC No. :                                                       NRIC No. :
                                                                Date       :                                                     Date       :



Notice :
1
*1. All Uni.Asia Life Assurance Berhad branches are equipped with facilities which would enable you to swipe your credit cards for on-line transactions. We urge you to exercise all
reasonable caution and proceed to our nearest branch to utilise the on-line credit card transaction facilities.
2. Kindly allow 10 days to process this form (applicable to recurring payment only)



                                                                      Uni.Asia Life Assurance Berhad (277714-A)
                                                         Bangunan Uni.Asia, No 16 Jalan Tun Tan Siew Sin, 50050 Kuala Lumpur
                                                                        Tel : 03-26872020 Fax : 03-20266097
                                                                            A DRB-Hicom & UOB company                                                                  CCDI/BC/01/10